Provider Demographics
NPI:1114396751
Name:LARSON, KRISTOPHER BRYCE (DMD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:BRYCE
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 E HUBER ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4022
Mailing Address - Country:US
Mailing Address - Phone:801-921-0792
Mailing Address - Fax:
Practice Address - Street 1:4050 E HUBER ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4022
Practice Address - Country:US
Practice Address - Phone:801-921-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00202672122300000X
AZD009505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist