Provider Demographics
NPI:1790288306
Name:LARSON, DALLIN (DDS)
Entity Type:Individual
Prefix:
First Name:DALLIN
Middle Name:
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 1:2289 N MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-8819
Mailing Address - Country:US
Mailing Address - Phone:208-859-4112
Mailing Address - Fax:
Practice Address - Street 1:3240 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5107
Practice Address - Country:US
Practice Address - Phone:208-898-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-10
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5309-EN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics