Provider Demographics
NPI:1881605053
Name:VASS, LARRY IVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:IVAN
Last Name:VASS
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 1:12070 OLD LINE CENTRE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2503
Mailing Address - Country:US
Mailing Address - Phone:301-645-8530
Mailing Address - Fax:301-843-8570
Practice Address - Street 1:12070 OLD LINE CENTRE
Practice Address - Street 2:SUITE 101
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2503
Practice Address - Country:US
Practice Address - Phone:301-645-8530
Practice Address - Fax:301-843-8570
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD6631122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist