Provider Demographics
NPI:1558568352
Name:LARSEN, BYRON (DDS)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:LARSEN
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 1:6120 W. BELL RD
Mailing Address - Street 2:STE 180
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:UM
Mailing Address - Phone:602-298-7200
Mailing Address - Fax:602-298-7202
Practice Address - Street 1:6120 W BELL RD
Practice Address - Street 2:STE 180
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3781
Practice Address - Country:US
Practice Address - Phone:602-298-7200
Practice Address - Fax:602-298-7202
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010186571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice