Provider Demographics
NPI:1710335872
Name:LARSON, JOSEPH ROBERT (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 HARVEY ST STE A
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-7861
Mailing Address - Country:US
Mailing Address - Phone:231-690-9083
Mailing Address - Fax:
Practice Address - Street 1:6207 HARVEY ST STE A
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7861
Practice Address - Country:US
Practice Address - Phone:231-690-9083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021920122300000X, 1223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program