Provider Demographics
NPI:1255772109
Name:LARSEN, BENNETT PACKARD (DDS)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:PACKARD
Last Name:LARSEN
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 1:223 140TH ST S
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-4531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 140TH ST S
Practice Address - Street 2:SUITE 800
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-4531
Practice Address - Country:US
Practice Address - Phone:253-537-1559
Practice Address - Fax:253-536-5907
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60384483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist