Provider Demographics
NPI:1245618099
Name:TODD S. LARSEN, DMD, PC
Entity Type:Organization
Organization Name:TODD S. LARSEN, DMD, PC
Other - Org Name:FORT UNION FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-562-2147
Mailing Address - Street 1:8915 S 700 E STE 103
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2421
Mailing Address - Country:US
Mailing Address - Phone:801-562-2147
Mailing Address - Fax:801-569-1795
Practice Address - Street 1:8915 S 700 E STE 103
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2421
Practice Address - Country:US
Practice Address - Phone:801-562-2147
Practice Address - Fax:801-569-1795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT360817-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty