Provider Demographics
NPI:1073826905
Name:LARSEN, JASON M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
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 1:2626 REAGAN ST
Mailing Address - Street 2:APT 327
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-3305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8528 DAVIS BLVD
Practice Address - Street 2:SUITE #100
Practice Address - City:N RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76182-8367
Practice Address - Country:US
Practice Address - Phone:817-605-8067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00257901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice