Provider Demographics
NPI:1912202508
Name:LAROSILIERE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:LAROSILIERE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROSILIERE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-773-7703
Mailing Address - Street 1:1401 MERCANTILE LN
Mailing Address - Street 2:102
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4301
Mailing Address - Country:US
Mailing Address - Phone:301-773-7703
Mailing Address - Fax:301-773-7708
Practice Address - Street 1:1401 MERCANTILE LN
Practice Address - Street 2:102
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4301
Practice Address - Country:US
Practice Address - Phone:301-773-7703
Practice Address - Fax:301-773-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD128111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC040018200Medicaid