Provider Demographics
NPI:1912462425
Name:THOMPSON, LARISA Y (RDH)
Entity type:Individual
Prefix:MRS
First Name:LARISA
Middle Name:Y
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8195 SPIRE CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3829
Mailing Address - Country:US
Mailing Address - Phone:719-232-9356
Mailing Address - Fax:
Practice Address - Street 1:6165 LEHMAN DR STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5405
Practice Address - Country:US
Practice Address - Phone:719-532-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO906003124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty