Provider Demographics
NPI:1972671071
Name:LARSON, GREGG A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGG
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 1:2716 UPPER AFTON ROAD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4780
Mailing Address - Country:US
Mailing Address - Phone:651-739-5110
Mailing Address - Fax:651-739-1873
Practice Address - Street 1:2716 UPPER AFTON ROAD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4780
Practice Address - Country:US
Practice Address - Phone:651-739-5110
Practice Address - Fax:651-739-1873
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7974122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN660715200Medicaid