Provider Demographics
NPI:1467594283
Name:LARSON, TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
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 1:1600 HERITAGE LNDG
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-8489
Mailing Address - Country:US
Mailing Address - Phone:636-441-3466
Mailing Address - Fax:636-441-5330
Practice Address - Street 1:1600 HERITAGE LNDG
Practice Address - Street 2:SUITE 210
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-8489
Practice Address - Country:US
Practice Address - Phone:636-441-3466
Practice Address - Fax:636-441-5330
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013328122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist