Provider Demographics
NPI:1740486794
Name:LARSEN, RAYMOND WALTER (DDS)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:WALTER
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 FOWLER WAY
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667
Mailing Address - Country:US
Mailing Address - Phone:530-622-3050
Mailing Address - Fax:530-622-7624
Practice Address - Street 1:1004 FOWLER WAY
Practice Address - Street 2:SUITE 8
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-622-3050
Practice Address - Fax:530-622-7624
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist