Provider Demographics
NPI:1720630908
Name:FLORES, LARISA POLET (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:POLET
Last Name:FLORES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 W WADLEY AVE APT N115
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-5170
Mailing Address - Country:US
Mailing Address - Phone:915-472-2278
Mailing Address - Fax:
Practice Address - Street 1:6109 E HIGHWAY 191
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5348
Practice Address - Country:US
Practice Address - Phone:432-272-8487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX353611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice