Provider Demographics
NPI:1265734347
Name:COLE, LARRY EDWARD
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:EDWARD
Last Name:COLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1298
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:WV
Mailing Address - Zip Code:25621-1298
Mailing Address - Country:US
Mailing Address - Phone:304-664-8163
Mailing Address - Fax:304-664-8193
Practice Address - Street 1:RT 52 MAIN STREET
Practice Address - Street 2:GILBERT
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621
Practice Address - Country:US
Practice Address - Phone:304-664-8163
Practice Address - Fax:304-664-8193
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133824000Medicaid