Provider Demographics
NPI:1184839912
Name:LARSEN, BRUCE MERRILL (DDS PC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MERRILL
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N STATE ST # 21
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:UT
Mailing Address - Zip Code:84647-1107
Mailing Address - Country:US
Mailing Address - Phone:435-462-2491
Mailing Address - Fax:435-462-3999
Practice Address - Street 1:240 N STATE ST # 21
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-1107
Practice Address - Country:US
Practice Address - Phone:435-462-2491
Practice Address - Fax:435-462-3999
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20-2063480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist