Provider Demographics
NPI:1598745382
Name:BULLOCK, LARRY JOEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JOEL
Last Name:BULLOCK
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 1:1550 TOMCAT BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23460-2218
Mailing Address - Country:US
Mailing Address - Phone:757-314-7190
Mailing Address - Fax:757-314-7064
Practice Address - Street 1:210A 88TH ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1828
Practice Address - Country:US
Practice Address - Phone:757-437-9005
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010084051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice