Provider Demographics
NPI:1295048692
Name:LARSON, CARL (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:LARSON
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 1:3909 E FAIRVIEW AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5814
Mailing Address - Country:US
Mailing Address - Phone:208-996-5808
Mailing Address - Fax:
Practice Address - Street 1:3909 E FAIRVIEW AVE STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5814
Practice Address - Country:US
Practice Address - Phone:208-996-5808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-45531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice