Provider Demographics
NPI:1205010287
Name:LARSEN FAMILY DENTISTRY, P.C.
Entity Type:Organization
Organization Name:LARSEN FAMILY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:COBURN
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-733-4778
Mailing Address - Street 1:PO BOX 4935
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4935
Mailing Address - Country:US
Mailing Address - Phone:307-733-4778
Mailing Address - Fax:307-734-8041
Practice Address - Street 1:3103 W BIG TRAIL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-9296
Practice Address - Country:US
Practice Address - Phone:307-733-4778
Practice Address - Fax:307-734-8041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118068100Medicaid