MEDICARE: LARRY JOHN RUSH DDS

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	471	CO

General Provider Information

NPI Number	:	1912153230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY JOHN RUSH DDS

Provider Business Mailing Address
First Line	:	2620 TENDERFOOT HILL ST
Second Line	:	SUITE 210
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8353
Country	:	US
Telephone Number	:	719-597-7979
Fax Number	:	719-597-8084

Provider Business Practice Location Address
First Line	:	2620 TENDERFOOT HILL ST
Second Line	:	SUITE 210
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8353
Country	:	US
Telephone Number	:	719-597-7979
Fax Number	:	719-597-8084

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

Provider Enumeration Date	:	08/18/2008
Last Update Date	:	08/18/2008

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