Provider Demographics
NPI:1407032113
Name:LARSEN, CLYDE S (DDS)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:S
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 1:190 N CARBON AVE
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2474
Mailing Address - Country:US
Mailing Address - Phone:435-637-0795
Mailing Address - Fax:
Practice Address - Street 1:190 N CARBON AVE
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2474
Practice Address - Country:US
Practice Address - Phone:435-637-0795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133591122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist