Provider Demographics
NPI:1346343373
Name:LARSEN, SCOTT COBURN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:COBURN
Last Name:LARSEN
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:PO BOX 4935
Mailing Address - Street 2:245 E BROADWAY
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001
Mailing Address - Country:US
Mailing Address - Phone:307-733-4778
Mailing Address - Fax:307-734-8041
Practice Address - Street 1:245 E BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-4778
Practice Address - Fax:307-734-8041
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118068100Medicaid