Provider Demographics
NPI:1730308313
Name:MUTH-LARSON, MEGAN LISABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:LISABETH
Last Name:MUTH-LARSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MEGAN
Other - Middle Name:LISABETH
Other - Last Name:MUTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:315 OXFORD ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5200
Mailing Address - Country:US
Mailing Address - Phone:503-362-3723
Mailing Address - Fax:503-364-7515
Practice Address - Street 1:315 OXFORD ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5200
Practice Address - Country:US
Practice Address - Phone:503-362-3723
Practice Address - Fax:503-364-7515
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD81221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice