Provider Demographics
NPI:1952564239
Name:TREADAWAY, LARRY WOODFIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WOODFIN
Last Name:TREADAWAY
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 1:504 S CLAY ST
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-4551
Mailing Address - Country:US
Mailing Address - Phone:972-875-6081
Mailing Address - Fax:972-875-5043
Practice Address - Street 1:504 S CLAY ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4551
Practice Address - Country:US
Practice Address - Phone:972-875-6081
Practice Address - Fax:972-875-5043
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice