Provider Demographics
NPI:1508133901
Name:LARSON, KATIE MIETTUNEN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:MIETTUNEN
Last Name:LARSON
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:KATIE
Other - Middle Name:ELIZABETH
Other - Last Name:MIETTUNEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:2966 MEADOWLARK LANE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720
Mailing Address - Country:US
Mailing Address - Phone:715-514-3333
Mailing Address - Fax:
Practice Address - Street 1:2966 MEADOWLARK LANE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720
Practice Address - Country:US
Practice Address - Phone:715-514-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND130271223X0400X
WI67900151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics