Provider Demographics
NPI:1467803874
Name:LARSON, COLLIN J (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:J
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2853
Mailing Address - Country:US
Mailing Address - Phone:219-229-0409
Mailing Address - Fax:
Practice Address - Street 1:3060 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4825
Practice Address - Country:US
Practice Address - Phone:269-327-5730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021965122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist