1891784039 NPI number — DR. LARRY G LYLES DDS

Table of content: DR. LARRY G LYLES DDS (NPI 1891784039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891784039 NPI number — DR. LARRY G LYLES DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYLES
Provider First Name:
LARRY
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1891784039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10506 FORESTGATE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENN DALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20769-2038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-809-0919
Provider Business Mailing Address Fax Number:
301-805-9696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7603 GEORGIA AVE NW
Provider Second Line Business Practice Location Address:
SUITE 403
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20012-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-723-8284
Provider Business Practice Location Address Fax Number:
301-990-1449
Provider Enumeration Date:
10/20/2005

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: 1223G0001X , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 298941 . This is a "MAMSI" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 39066-1 . This is a "DENTAL BENEFITS PROVIDER" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 104722 . This is a "DORAL DENTAL" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 8533 . This is a "BCBS OF MD" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 783970 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 0800120 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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