Provider Demographics
NPI:1255569927
Name:LARSON, RICKY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:RICKY
Middle Name:LEE
Last Name:LARSON
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 1:546 E SANDY LAKE RD STE 240
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-5790
Mailing Address - Country:US
Mailing Address - Phone:972-304-0489
Mailing Address - Fax:972-745-6799
Practice Address - Street 1:546 E SANDY LAKE RD STE 240
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5790
Practice Address - Country:US
Practice Address - Phone:972-304-0489
Practice Address - Fax:972-745-6799
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX253961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice