Provider Demographics
NPI:1619005790
Name:LARSON, LEWIS C (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:C
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 FRONT ST
Mailing Address - Street 2:#310
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4991
Mailing Address - Country:US
Mailing Address - Phone:407-566-2222
Mailing Address - Fax:407-566-1650
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:A-260
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-566-2222
Practice Address - Fax:407-566-1650
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 74431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics