Provider Demographics
NPI:1467977223
Name:LARSON, CAROLINE (DMD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 TOSCANA DR APT 1537
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3588
Mailing Address - Country:US
Mailing Address - Phone:239-887-0382
Mailing Address - Fax:
Practice Address - Street 1:2700 NE 14TH STREET CSWY STE 105
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3561
Practice Address - Country:US
Practice Address - Phone:954-941-2412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-13
Last Update Date:2017-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist