Provider Demographics
NPI:1013320142
Name:HANSON, LARISSA W (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:W
Last Name:HANSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 S ATLANTIC AVE APT 1805
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:32118-6048
Mailing Address - Country:US
Mailing Address - Phone:386-760-1200
Mailing Address - Fax:
Practice Address - Street 1:3777 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3528
Practice Address - Country:US
Practice Address - Phone:386-760-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN206401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice