Provider Demographics
NPI:1649335670
Name:ABBOTT, LARRY EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:EDWARD
Last Name:ABBOTT
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 1:620 TENNESSEE AVE
Mailing Address - Street 2:PO BOX 517
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-1304
Mailing Address - Country:US
Mailing Address - Phone:423-263-7315
Mailing Address - Fax:423-263-5055
Practice Address - Street 1:620 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-1304
Practice Address - Country:US
Practice Address - Phone:423-263-7315
Practice Address - Fax:423-263-5055
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS003274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist