Provider Demographics
NPI:1235435744
Name:LARSON, DONALD E (DMD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:E
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 1:5919 N LILYBROOK PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1381
Mailing Address - Country:US
Mailing Address - Phone:208-939-1570
Mailing Address - Fax:208-939-1570
Practice Address - Street 1:700 E STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5941
Practice Address - Country:US
Practice Address - Phone:208-939-3500
Practice Address - Fax:208-939-9897
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD35511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8061442Medicaid
IDCS9245OtherID STATE BOARD OF PHARMACY
ID1312746OtherUNITED CONCORDIA