Provider Demographics
NPI:1003838459
Name:LARSON, STEPHEN M (DMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1173
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6411 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-6200
Practice Address - Fax:713-500-6201
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11353207L00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X6137OtherBCBS
TX102216202Medicaid
TX84214FOtherBCBS
TX84214FOtherBCBS
TX8X6137OtherBCBS
TX8K6917Medicare PIN
TXU11063Medicare UPIN