Healthcare Provider Details

I. General information

NPI: 1386700839
Provider Name (Legal Business Name): LARRY D DORMOIS D.D.S, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 UNION AVE
MEMPHIS TN
38103
US

IV. Provider business mailing address

7118 BELL MANOR CV
GERMANTOWN TN
38138-1900
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-6240
  • Fax:
Mailing address:
  • Phone: 901-758-8066
  • Fax: 901-448-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2335
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3545
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: