Provider Demographics
NPI:1326368432
Name:LARSON, CLARK DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:DAVID
Last Name:LARSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24433 S 201ST CT
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5097
Mailing Address - Country:US
Mailing Address - Phone:480-310-7721
Mailing Address - Fax:
Practice Address - Street 1:270 E HUNT HWY STE 14
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4964
Practice Address - Country:US
Practice Address - Phone:480-888-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25454122300000X
AZ8141122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist