Provider Demographics
NPI:1861637613
Name:TOLLEY, LARISSA MAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:MAE
Last Name:TOLLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-6315
Mailing Address - Country:US
Mailing Address - Phone:303-345-4187
Mailing Address - Fax:
Practice Address - Street 1:1347 S. BEVERLY
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4133
Practice Address - Country:US
Practice Address - Phone:307-577-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice