Provider Demographics
NPI:1093874885
Name:LARSON, KAREN NELSON (DDS)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:NELSON
Last Name:LARSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 WEBB AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2923
Mailing Address - Country:US
Mailing Address - Phone:510-521-9800
Mailing Address - Fax:510-521-1862
Practice Address - Street 1:2420 WEBB AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2923
Practice Address - Country:US
Practice Address - Phone:510-521-9800
Practice Address - Fax:510-521-1862
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0341411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942997070OtherTAX IDENTIFICATION NUMBER