MEDICARE: DR. LARRY J ONEILL D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7544	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1170084826	OTHER		NPPES

General Provider Information

NPI Number	:	1174521348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY J ONEILL D.M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2466
Second Line	:
City	:	ELIZABETH
State	:	CO
Zip	:	80107-2466
Country	:	US
Telephone Number	:	303-646-3935
Fax Number	:	303-379-5380

Provider Business Practice Location Address
First Line	:	779 CROSSROADS CR
Second Line	:
City	:	ELIZABETH
State	:	CO
Zip	:	80107-7466
Country	:	US
Telephone Number	:	303-646-3935
Fax Number	:	303-379-5380

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	04/07/2021

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