Provider Demographics
NPI:1720291214
Name:RICKBORN, LARRY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:RICKBORN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3420
Mailing Address - Country:US
Mailing Address - Phone:803-731-0803
Mailing Address - Fax:803-227-2844
Practice Address - Street 1:2844 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3420
Practice Address - Country:US
Practice Address - Phone:803-731-0803
Practice Address - Fax:803-227-2844
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice