Provider Demographics
NPI:1962669283
Name:FICKLIN, LARRY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:R
Last Name:FICKLIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MO
Mailing Address - Zip Code:63068-1143
Mailing Address - Country:US
Mailing Address - Phone:573-237-3038
Mailing Address - Fax:573-237-2987
Practice Address - Street 1:104 MILLER ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MO
Practice Address - Zip Code:63068-1143
Practice Address - Country:US
Practice Address - Phone:573-237-3038
Practice Address - Fax:573-237-2987
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO012855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist