Provider Demographics
NPI:1578655809
Name:LARISCY, LLOYD WADE (DDS)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:WADE
Last Name:LARISCY
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 1:24924 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1740
Mailing Address - Country:US
Mailing Address - Phone:313-274-8522
Mailing Address - Fax:313-274-5396
Practice Address - Street 1:24924 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1740
Practice Address - Country:US
Practice Address - Phone:313-274-8522
Practice Address - Fax:313-274-5396
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0132871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics