Provider Demographics
NPI:1639567043
Name:LARSEN-HASLEM DENTAL LLC
Entity Type:Organization
Organization Name:LARSEN-HASLEM DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAREN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-781-2729
Mailing Address - Street 1:1214 W 500 S
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2916
Mailing Address - Country:US
Mailing Address - Phone:435-781-2729
Mailing Address - Fax:435-781-2719
Practice Address - Street 1:1214 W 500 S
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2916
Practice Address - Country:US
Practice Address - Phone:435-781-2729
Practice Address - Fax:435-781-2719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3411869922261QD0000X
UT65632849922261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental