MEDICARE: DR. LARRY EUGENE DALZELL PH.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	231H00000X	Audiologist	000386-1	NY

General Provider Information

NPI Number	:	1942278718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY EUGENE DALZELL PH.D.

Provider Business Mailing Address
First Line	:	175 GLENHILL DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-3933
Country	:	US
Telephone Number	:	585-442-6392
Fax Number	:

Provider Business Practice Location Address
First Line	:	2561 LAC DE VILLE BLVD
Second Line	:	# 101
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5645
Country	:	US
Telephone Number	:	585-461-9192
Fax Number	:	585-461-9196

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	07/08/2007

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