Provider Demographics
NPI:1992036495
Name:EARL R. LARSON, D.D.S., P.C.
Entity Type:Organization
Organization Name:EARL R. LARSON, D.D.S., P.C.
Other - Org Name:WILDHORSE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-537-0447
Mailing Address - Street 1:150 LONG ROAD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005
Mailing Address - Country:US
Mailing Address - Phone:636-537-0447
Mailing Address - Fax:636-537-9452
Practice Address - Street 1:150 LONG ROAD STE 100
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005
Practice Address - Country:US
Practice Address - Phone:636-537-0447
Practice Address - Fax:636-537-9452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty