Provider Demographics
NPI:1770647307
Name:LARSEN, ROBERT BRUCE (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRUCE
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 1:18839 AGIN CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4481
Mailing Address - Country:US
Mailing Address - Phone:210-479-1851
Mailing Address - Fax:
Practice Address - Street 1:1615 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-5511
Practice Address - Country:US
Practice Address - Phone:210-292-6335
Practice Address - Fax:210-292-2740
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1050921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice