Provider Demographics
NPI:1629156500
Name:LARSON, JENNIFER SUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
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 1:216 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1210
Mailing Address - Country:US
Mailing Address - Phone:231-350-6747
Mailing Address - Fax:231-582-4460
Practice Address - Street 1:216 N LAKE ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1210
Practice Address - Country:US
Practice Address - Phone:231-582-4480
Practice Address - Fax:231-582-4460
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901019425OtherSTATE OF MICHIGAN BOARD OF DENTISTRY
MI4916278Medicaid