Provider Demographics
NPI:1710180807
Name:HAMMER, LARISSA GARDNER (DMD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:GARDNER
Last Name:HAMMER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 S LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5224
Mailing Address - Country:US
Mailing Address - Phone:662-236-1969
Mailing Address - Fax:662-513-5878
Practice Address - Street 1:2162 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5224
Practice Address - Country:US
Practice Address - Phone:662-236-1969
Practice Address - Fax:662-513-5878
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3447-081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07458861Medicaid