Provider Demographics
NPI:1942657960
Name:PAUL C LARSEN DMD PC
Entity Type:Organization
Organization Name:PAUL C LARSEN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-295-8881
Mailing Address - Street 1:415 MEDICAL DR
Mailing Address - Street 2:STE D201
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4946
Mailing Address - Country:US
Mailing Address - Phone:801-295-8881
Mailing Address - Fax:801-203-2947
Practice Address - Street 1:415 MEDICAL DR
Practice Address - Street 2:STE D201
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4946
Practice Address - Country:US
Practice Address - Phone:801-295-8881
Practice Address - Fax:801-203-2947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5332372-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty