Provider Demographics
NPI:1225759111
Name:LAKE HAVASU ORTHODONTICS LLC
Entity Type:Organization
Organization Name:LAKE HAVASU ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:253-283-2747
Mailing Address - Street 1:2212 E ARIS DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-1205
Mailing Address - Country:US
Mailing Address - Phone:253-283-2747
Mailing Address - Fax:
Practice Address - Street 1:2061 SMOKETREE AVE N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5811
Practice Address - Country:US
Practice Address - Phone:928-854-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty