Provider Demographics
NPI:1891096079
Name:LARSON, CYRUS MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CYRUS
Middle Name:MICHAEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 SOUTH AVE W
Mailing Address - Street 2:SUITE B
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8020
Mailing Address - Country:US
Mailing Address - Phone:801-310-7039
Mailing Address - Fax:
Practice Address - Street 1:628 SOUTH AVE W
Practice Address - Street 2:SUITE B
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8020
Practice Address - Country:US
Practice Address - Phone:801-310-7039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT96301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice