MEDICARE: DR. LARRY WILSON SPRADLEY D.D.S., M.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	9829	TX

General Provider Information

NPI Number	:	1386637536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY WILSON SPRADLEY D.D.S., M.S.

Provider Business Mailing Address
First Line	:	4224 HERITAGE TRACE PKWY STE 304
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5379
Country	:	US
Telephone Number	:	817-741-2200
Fax Number	:	817-741-2216

Provider Business Practice Location Address
First Line	:	4224 HERITAGE TRACE PKWY STE 304
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5379
Country	:	US
Telephone Number	:	817-741-2200
Fax Number	:	817-741-2216

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	02/18/2011

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