1205010287 NPI number — LARSEN FAMILY DENTISTRY, P.C.

Table of content: (NPI 1205010287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205010287 NPI number — LARSEN FAMILY DENTISTRY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARSEN FAMILY DENTISTRY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205010287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4935
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83001-4935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-733-4778
Provider Business Mailing Address Fax Number:
307-734-8041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3103 W BIG TRAIL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001-9296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-733-4778
Provider Business Practice Location Address Fax Number:
307-734-8041
Provider Enumeration Date:
12/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
COBURN
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
307-733-4778

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 118068100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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