Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 11305 | TX |
NPI | 1013025121 |
---|---|
Provider Name | Dr. Larry Mike Bloodsworth |
First Address | Tyler, TX 75701 |
Second Address | Tyler, TX 75701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2006 |
Last Update Date | 08/07/2007 |