Provider Demographics
NPI:1851667364
Name:LARSON ORTHODONTIC SPECIALISTS
Entity Type:Organization
Organization Name:LARSON ORTHODONTIC SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:651-366-9754
Mailing Address - Street 1:431 E CLAIREMONT AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3685
Mailing Address - Country:US
Mailing Address - Phone:715-514-3333
Mailing Address - Fax:888-837-7347
Practice Address - Street 1:431 E CLAIREMONT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3685
Practice Address - Country:US
Practice Address - Phone:715-514-3333
Practice Address - Fax:888-837-7347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty