Provider Demographics
NPI:1164198842
Name:LARSON, IAN JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:JAMES
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 1:23 S WASHINGTON AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:MARGATE CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08402-2303
Mailing Address - Country:US
Mailing Address - Phone:609-822-0911
Mailing Address - Fax:
Practice Address - Street 1:23 S WASHINGTON AVE STE 1A
Practice Address - Street 2:
Practice Address - City:MARGATE CITY
Practice Address - State:NJ
Practice Address - Zip Code:08402-2303
Practice Address - Country:US
Practice Address - Phone:609-822-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02851100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist