Healthcare Provider Details

I. General information

NPI: 1508966961
Provider Name (Legal Business Name): LARRY L CUNNINGHAM JR. DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 TERRACE STREET SUITE 3189
PITSBURGH PA
15213-2523
US

IV. Provider business mailing address

3501 TERRACE STREET SUITE 3189
PITTSBURGH PA
15213-2523
US

V. Phone/Fax

Practice location:
  • Phone: 412-648-9100
  • Fax: 412-383-7862
Mailing address:
  • Phone: 412-648-9100
  • Fax: 412-383-7862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7704
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number7704
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDS042379
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS042379
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: