=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558469312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY D SPARKS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 N MAIN
-----------------------------------------------------
City | WEST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76691-0369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-826-4067
-----------------------------------------------------
Fax | 254-826-4589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 369 312 N MAIN
-----------------------------------------------------
City | WEST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76691-0369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-826-4067
-----------------------------------------------------
Fax | 254-826-4589
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | TX14129
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------