Provider Demographics
NPI:1093926388
Name:LARSON, ELDON WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELDON
Middle Name:WESLEY
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 1:19170 8TH AVE NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8773
Mailing Address - Country:US
Mailing Address - Phone:360-779-3633
Mailing Address - Fax:360-779-6232
Practice Address - Street 1:19170 8TH AVE NE
Practice Address - Street 2:SUITE B
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8773
Practice Address - Country:US
Practice Address - Phone:360-779-3633
Practice Address - Fax:360-779-6232
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA43641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice