Provider Demographics
NPI:1417099813
Name:LARSON, THOMAS JOE (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOE
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:PO BOX 800
Mailing Address - Street 2:800 CLINIC CIRCLE
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031
Mailing Address - Country:US
Mailing Address - Phone:507-235-5985
Mailing Address - Fax:
Practice Address - Street 1:800 CLINIC CIRCLE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031
Practice Address - Country:US
Practice Address - Phone:507-235-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN95021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice