Provider Demographics
NPI:1629362017
Name:LARSEN, ANDREA KAY (DDS)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:KAY
Last Name:LARSEN
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 1:210 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2310
Mailing Address - Country:US
Mailing Address - Phone:920-885-6066
Mailing Address - Fax:
Practice Address - Street 1:210 MADISON ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2310
Practice Address - Country:US
Practice Address - Phone:920-885-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6701-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist