Provider Demographics
NPI:1114010188
Name:LARSEN, SUSAN MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MICHELLE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MICHELLE
Other - Last Name:MATCHINSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1245 E SOUTHERN AVE
Mailing Address - Street 2:STE 12
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5137
Mailing Address - Country:US
Mailing Address - Phone:480-610-6544
Mailing Address - Fax:480-633-0670
Practice Address - Street 1:1245 E SOUTHERN AVE
Practice Address - Street 2:STE 12
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5137
Practice Address - Country:US
Practice Address - Phone:480-610-6544
Practice Address - Fax:480-633-0670
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ703323Medicaid