1780625772 NPI number — GREGG STUART LARSON DDS

Table of content: GREGG STUART LARSON DDS (NPI 1780625772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780625772 NPI number — GREGG STUART LARSON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
GREGG
Provider Middle Name:
STUART
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1780625772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 CENTRACARE CIRCLE
Provider Second Line Business Mailing Address:
STE 0350
Provider Business Mailing Address City Name:
ST CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-253-0272
Provider Business Mailing Address Fax Number:
320-251-2661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 CENTRACARE CIRCLE
Provider Second Line Business Practice Location Address:
STE 0350
Provider Business Practice Location Address City Name:
ST CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-253-0272
Provider Business Practice Location Address Fax Number:
320-251-2661
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  11344 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 286909800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 294L9LA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP37202 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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