Provider Demographics
NPI:1093185118
Name:KEITH R LARSON DMD PC
Entity Type:Organization
Organization Name:KEITH R LARSON DMD PC
Other - Org Name:APNEA AND SNORING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RODNEY
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PC
Authorized Official - Phone:503-292-0416
Mailing Address - Street 1:17895 NW EVERGREEN PKWY
Mailing Address - Street 2:130
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7402
Mailing Address - Country:US
Mailing Address - Phone:503-716-6712
Mailing Address - Fax:503-536-6617
Practice Address - Street 1:17895 NW EVERGREEN PKWY
Practice Address - Street 2:130
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7402
Practice Address - Country:US
Practice Address - Phone:503-716-6712
Practice Address - Fax:503-536-6617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD4338332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment