Healthcare Provider Details

I. General information

NPI: 1962669283
Provider Name (Legal Business Name): LARRY R FICKLIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MILLER ST
NEW HAVEN MO
63068-1143
US

IV. Provider business mailing address

104 MILLER ST
NEW HAVEN MO
63068-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-237-3038
  • Fax: 573-237-2987
Mailing address:
  • Phone: 573-237-3038
  • Fax: 573-237-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number012855
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: