Provider Demographics
NPI:1124303995
Name:FREYTAG, LARISSA E (DMD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:E
Last Name:FREYTAG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11880 COLLEGE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2188
Mailing Address - Country:US
Mailing Address - Phone:913-951-0757
Mailing Address - Fax:
Practice Address - Street 1:9740 N ORACLE RD STE 100
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85704-7614
Practice Address - Country:US
Practice Address - Phone:520-365-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS605811223X0400X
AZD0091791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics