Provider Demographics
NPI:1780842526
Name:LARSON, ALISHA MARIE (RDH BS)
Entity Type:Individual
Prefix:MRS
First Name:ALISHA
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:RDH BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 MCDOUGALL DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3531
Mailing Address - Country:US
Mailing Address - Phone:307-335-5960
Mailing Address - Fax:
Practice Address - Street 1:29 BLACK COAL DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-3527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY747124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist