Provider Demographics
NPI:1720015068
Name:GARY A. LARSEN, DDS, INC.
Entity Type:Organization
Organization Name:GARY A. LARSEN, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALLYN
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-226-6060
Mailing Address - Street 1:2812 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-3437
Mailing Address - Country:US
Mailing Address - Phone:559-322-9679
Mailing Address - Fax:559-226-6062
Practice Address - Street 1:1275 W SHAW AVE STE 110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3710
Practice Address - Country:US
Practice Address - Phone:559-226-6060
Practice Address - Fax:559-226-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41749122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty