Provider Demographics
NPI:1699825190
Name:ANDERSON, LARRY DOUGLAS (DDS, ABGD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DOUGLAS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS, ABGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:DEADWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57732-0154
Mailing Address - Country:US
Mailing Address - Phone:605-578-7519
Mailing Address - Fax:605-578-7519
Practice Address - Street 1:11736 IMPRESSIVE VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732-0154
Practice Address - Country:US
Practice Address - Phone:605-578-7519
Practice Address - Fax:605-578-7519
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA290121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice