Provider Demographics
NPI:1679672828
Name:LARRY E LANDERS DDS PC
Entity Type:Organization
Organization Name:LARRY E LANDERS DDS PC
Other - Org Name:LARRY E LANDERS DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT LARRY E LANDERS DDS PC
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-741-3683
Mailing Address - Street 1:155 COLLEGE STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-741-3688
Mailing Address - Fax:478-741-0912
Practice Address - Street 1:155 COLLEGE STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-741-3688
Practice Address - Fax:478-741-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN007343122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1133153OtherDRUG ENFORCEMENT AGENCY