Provider Demographics
NPI:1619039922
Name:LARSON, SANDRA SUE (DDS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SUE
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 1:1919 SOUTH 40TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-5247
Mailing Address - Country:US
Mailing Address - Phone:402-483-1054
Mailing Address - Fax:402-483-1056
Practice Address - Street 1:1919 SOUTH 40TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5247
Practice Address - Country:US
Practice Address - Phone:402-483-1054
Practice Address - Fax:402-483-1056
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47072666100Medicaid