Provider Demographics
NPI:1376570242
Name:LARSEN, MICHAEL ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:LARSEN
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 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:208-734-5036
Practice Address - Street 1:1361 E 16TH ST
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2008
Practice Address - Country:US
Practice Address - Phone:208-677-5198
Practice Address - Fax:208-678-2245
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE10258122300000X
IDD-39931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050232Medicaid
ID807518200Medicaid