Provider Demographics
NPI:1710171483
Name:LARSON, ROBERT GARDNER (DDS MSD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GARDNER
Last Name:LARSON
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6070 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2585
Mailing Address - Country:US
Mailing Address - Phone:317-253-6784
Mailing Address - Fax:317-803-9917
Practice Address - Street 1:6070 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2585
Practice Address - Country:US
Practice Address - Phone:317-253-6784
Practice Address - Fax:317-803-9917
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8110122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist