Provider Demographics
NPI:1891829941
Name:LARSON, BRENT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
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 1:928 E 100 S
Mailing Address - Street 2:STE #A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1455
Mailing Address - Country:US
Mailing Address - Phone:801-355-5558
Mailing Address - Fax:801-322-0629
Practice Address - Street 1:928 E 100 S
Practice Address - Street 2:STE #A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1455
Practice Address - Country:US
Practice Address - Phone:801-355-5558
Practice Address - Fax:801-322-0629
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139116-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice