Provider Demographics
NPI:1154509677
Name:LARSON, LAURA LEE (RDH)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:LEE
Last Name:LARSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 898
Mailing Address - Street 2:
Mailing Address - City:RUNNING SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92382-0898
Mailing Address - Country:US
Mailing Address - Phone:909-867-1145
Mailing Address - Fax:
Practice Address - Street 1:27201 HIGHWAY 189
Practice Address - Street 2:
Practice Address - City:BLUE JAY
Practice Address - State:CA
Practice Address - Zip Code:92317
Practice Address - Country:US
Practice Address - Phone:909-337-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16999124Q00000X, 126900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No126900000XDental ProvidersDental Laboratory Technician