Provider Demographics
NPI:1659466753
Name:BUNTYN, LARRY ROSS SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ROSS
Last Name:BUNTYN
Suffix:SR
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 1:14070 DEDEAUX RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4502
Mailing Address - Country:US
Mailing Address - Phone:228-832-1951
Mailing Address - Fax:228-832-5558
Practice Address - Street 1:14070 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4502
Practice Address - Country:US
Practice Address - Phone:228-832-1951
Practice Address - Fax:228-832-5558
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1228-67122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist