Provider Demographics
NPI:1912153230
Name:RUSH, LARRY JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JOHN
Last Name:RUSH
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 1:2620 TENDERFOOT HILL ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8353
Mailing Address - Country:US
Mailing Address - Phone:719-597-7979
Mailing Address - Fax:719-597-8084
Practice Address - Street 1:2620 TENDERFOOT HILL ST
Practice Address - Street 2:SUITE 210
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8353
Practice Address - Country:US
Practice Address - Phone:719-597-7979
Practice Address - Fax:719-597-8084
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice