Provider Demographics
NPI:1720119845
Name:LARSON, AMY L (RDH)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:LARSON
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 1:1408 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SOBIESKI
Mailing Address - State:WI
Mailing Address - Zip Code:54171-9717
Mailing Address - Country:US
Mailing Address - Phone:920-826-6655
Mailing Address - Fax:
Practice Address - Street 1:1400 LOMBARDI AVE
Practice Address - Street 2:SUITE 50
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-3922
Practice Address - Country:US
Practice Address - Phone:920-498-8877
Practice Address - Fax:920-498-8941
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4743124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist