Provider Demographics
NPI:1740353564
Name:LARSON, DANIEL A
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 DELAWARE ST SE
Mailing Address - Street 2:SCHOOL OF DENTISTRY
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0357
Mailing Address - Country:US
Mailing Address - Phone:612-624-8600
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST NE
Practice Address - Street 2:7TH FLOOR MOOS TOWER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0329
Practice Address - Country:US
Practice Address - Phone:612-624-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND65691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery