Healthcare Provider Details

I. General information

NPI: 1912462425
Provider Name (Legal Business Name): LARISA Y THOMPSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 LEHMAN DR STE 100
COLORADO SPRINGS CO
80918-5405
US

IV. Provider business mailing address

8195 SPIRE CT
COLORADO SPRINGS CO
80919-3829
US

V. Phone/Fax

Practice location:
  • Phone: 719-532-0707
  • Fax:
Mailing address:
  • Phone: 719-232-9356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number906003
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: