Larry Lee Jack, DDS
Individual provider Active NPI Dentist · Leadville, CO
NPI 1386982247 · NPPES record last updated Jan 27, 2013
Key facts
- NPI
- 1386982247
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 7752 (CO)
- Practice address
- 404 E 7TH St
Leadville, CO 80461-3131 - Phone
- (410) 980-5433
- NPI assigned
- Jan 27, 2013
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CO
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20151230002400 | CO | Order and Referring Only - Oral Surgery |
0446552822 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7752 | CO | MD | Dentist |
| 9327 | MD | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 7752 | CO | Yes |
| Dentist | 122300000X | 9327 | MD |
Addresses
Primary practice location
404 E 7TH St
Leadville, CO 80461-3131
Mailing address
PO Box 476
Leadville, CO 80461-0476
Other providers in Leadville, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 27, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.