1558321455 NPI number — DR. LARRY MICHAEL OVER DMD,MSD

Table of content: DR. LARRY MICHAEL OVER DMD,MSD (NPI 1558321455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558321455 NPI number — DR. LARRY MICHAEL OVER DMD,MSD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OVER
Provider First Name:
LARRY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD,MSD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558321455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2340 LAKEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97408-4501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-687-7860
Provider Business Mailing Address Fax Number:
541-338-0255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 COUNTRY CLUB RD.
Provider Second Line Business Practice Location Address:
STE 240
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-687-1499
Provider Business Practice Location Address Fax Number:
541-338-0255
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  6294 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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