Provider Demographics
NPI:1073758843
Name:IVERSON & LARSEN DENTAL PLLC
Entity Type:Organization
Organization Name:IVERSON & LARSEN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERN
Authorized Official - Middle Name:Q
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-745-3882
Mailing Address - Street 1:2627 N HIGHWAY 162
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310-9745
Mailing Address - Country:US
Mailing Address - Phone:801-745-3882
Mailing Address - Fax:801-745-6207
Practice Address - Street 1:2627 N HIGHWAY 162
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:UT
Practice Address - Zip Code:84310-9745
Practice Address - Country:US
Practice Address - Phone:801-745-3882
Practice Address - Fax:801-745-6207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental