Provider Demographics
NPI:1891784039
Name:LYLES, LARRY G (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:G
Last Name:LYLES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:10506 FORESTGATE PL
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-2038
Mailing Address - Country:US
Mailing Address - Phone:301-809-0919
Mailing Address - Fax:301-805-9696
Practice Address - Street 1:7603 GEORGIA AVE NW
Practice Address - Street 2:SUITE 403
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1617
Practice Address - Country:US
Practice Address - Phone:202-723-8284
Practice Address - Fax:301-990-1449
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC298941OtherMAMSI
DC39066-1OtherDENTAL BENEFITS PROVIDER
DC104722OtherDORAL DENTAL
DC8533OtherBCBS OF MD
DC783970OtherUNITED CONCORDIA
DC0800120Medicaid