Provider Demographics
NPI:1245613249
Name:LARSON, BRYCE ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:ALAN
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 1:618 S MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2516
Mailing Address - Country:US
Mailing Address - Phone:847-508-9490
Mailing Address - Fax:
Practice Address - Street 1:28377 DAVIS PKWY STE 609
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555
Practice Address - Country:US
Practice Address - Phone:630-836-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist