Provider Demographics
NPI:1417081308
Name:LARSON, ERIC A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
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 1:928 EAST 100 SOUTH
Mailing Address - Street 2:STE #B
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-8410
Mailing Address - Country:US
Mailing Address - Phone:801-355-4733
Mailing Address - Fax:801-322-0629
Practice Address - Street 1:928 E 100 S
Practice Address - Street 2:STE #B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1455
Practice Address - Country:US
Practice Address - Phone:801-355-4733
Practice Address - Fax:801-322-0629
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT334445-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT80012476OtherTIN #