Provider Demographics
NPI:1891194536
Name:LARSEN, CHERYL (RDH)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2730
Mailing Address - Country:US
Mailing Address - Phone:218-628-7035
Mailing Address - Fax:218-722-6239
Practice Address - Street 1:3600 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5589
Practice Address - Country:US
Practice Address - Phone:715-394-5411
Practice Address - Fax:715-392-5086
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10460124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist