Provider Demographics
NPI:1265165054
Name:LARSEN, ALICIA MARIE (RDH)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:MARIE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 BRAND RD
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NY
Mailing Address - Zip Code:14433-9728
Mailing Address - Country:US
Mailing Address - Phone:315-604-7257
Mailing Address - Fax:
Practice Address - Street 1:140 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2839
Practice Address - Country:US
Practice Address - Phone:315-789-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031238124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031238Medicaid