Provider Demographics
NPI:1093711848
Name:LARSON, MICHAEL JOE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOE
Last Name:LARSON
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 1:27767 WHIRLAWAY TRL
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-6463
Mailing Address - Country:US
Mailing Address - Phone:303-674-8229
Mailing Address - Fax:
Practice Address - Street 1:30940 STAGECOACH BLVD
Practice Address - Street 2:STE E250
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7984
Practice Address - Country:US
Practice Address - Phone:303-674-6777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COH-D-1-043311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice