Provider Demographics
NPI:1336126697
Name:LARSEN, STACY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNN
Last Name:LARSEN
Suffix:
Gender:F
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:DEPARTMENT OF THE ARMY DENTAL ACTIVITY STOP
Mailing Address - Street 2:2817 REILLY RD, MCDS-NA-B
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-396-5610
Mailing Address - Fax:910-396-7017
Practice Address - Street 1:DEPARTMENT OF THE ARMY DENTAL ACTIVITY STOP
Practice Address - Street 2:2817 REILLY RD, MCDS-NA-B
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-396-5610
Practice Address - Fax:910-396-7017
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE62831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice