Provider Demographics
NPI:1467547059
Name:LARSON, ROBERT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
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:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0270
Mailing Address - Country:US
Mailing Address - Phone:509-837-4213
Mailing Address - Fax:509-839-5305
Practice Address - Street 1:412 S 13TH ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-1571
Practice Address - Country:US
Practice Address - Phone:509-837-4213
Practice Address - Fax:509-839-5305
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000069991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice