Provider Demographics
NPI:1750444758
Name:LARSON, DOUGLAS KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KEITH
Last Name:LARSON
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 1:42 W CAMPBELL AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1042
Mailing Address - Country:US
Mailing Address - Phone:408-374-6160
Mailing Address - Fax:408-374-6474
Practice Address - Street 1:42 W CAMPBELL AVE STE 204
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1042
Practice Address - Country:US
Practice Address - Phone:408-374-6160
Practice Address - Fax:408-374-6474
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30698122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist