Provider Demographics
NPI:1689860579
Name:MADSEN, LARRY F (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:F
Last Name:MADSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 JUANA AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4838
Mailing Address - Country:US
Mailing Address - Phone:510-352-2111
Mailing Address - Fax:
Practice Address - Street 1:299 JUANA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4838
Practice Address - Country:US
Practice Address - Phone:510-352-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA229061223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22906OtherDENTAL LICENSE NUMBER