Provider Demographics
NPI:1528184660
Name:LARSON, STEPHANIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
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 845
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-0845
Mailing Address - Country:US
Mailing Address - Phone:651-462-7017
Mailing Address - Fax:
Practice Address - Street 1:26357 FOREST BLVD
Practice Address - Street 2:STE 2
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8353
Practice Address - Country:US
Practice Address - Phone:651-462-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist