Provider Demographics
NPI:1528226552
Name:TADLOCK, LARRY P (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:P
Last Name:TADLOCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S MAIN ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-7029
Mailing Address - Country:US
Mailing Address - Phone:817-485-4996
Mailing Address - Fax:817-741-8421
Practice Address - Street 1:601 S MAIN ST
Practice Address - Street 2:SUITE 240
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-7029
Practice Address - Country:US
Practice Address - Phone:817-485-4996
Practice Address - Fax:817-741-8421
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX142541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics