Provider Demographics
NPI:1699194530
Name:LARSEN, DUSTIN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2199 N MERRIT CRK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4949
Mailing Address - Country:US
Mailing Address - Phone:435-881-4966
Mailing Address - Fax:
Practice Address - Street 1:2199 N MERRIT CRK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4949
Practice Address - Country:US
Practice Address - Phone:208-665-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13761207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology