Provider Demographics
NPI:1013014471
Name:LARSEN, RUSSELL M (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:M
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-3706
Mailing Address - Country:US
Mailing Address - Phone:360-249-3151
Mailing Address - Fax:360-249-5129
Practice Address - Street 1:208 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-3706
Practice Address - Country:US
Practice Address - Phone:360-249-3151
Practice Address - Fax:360-249-5129
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5032016Medicaid