Provider Demographics
NPI:1720239833
Name:PITZAK, LARRY VERNON (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:VERNON
Last Name:PITZAK
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 1:43983 MEDINAH DR
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-8901
Mailing Address - Country:US
Mailing Address - Phone:714-396-4025
Mailing Address - Fax:714-960-4285
Practice Address - Street 1:43983 MEDINAH DR
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-8901
Practice Address - Country:US
Practice Address - Phone:714-396-4025
Practice Address - Fax:714-960-4285
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA256111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice