Provider Demographics
NPI:1942362892
Name:LARSON, WILLIAM KEAT (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KEAT
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 1:211 SOUTH 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560
Mailing Address - Country:US
Mailing Address - Phone:218-233-0429
Mailing Address - Fax:218-291-1640
Practice Address - Street 1:211 SOUTH 5TH STREET
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:218-233-0429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist