Provider Demographics
NPI:1750450227
Name:LARSON, BRANDY LEEANN (DDS)
Entity type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:LEEANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:BRANDY
Other - Middle Name:LEEANN
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3522 QUINCY DR SW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601
Mailing Address - Country:US
Mailing Address - Phone:218-335-3234
Mailing Address - Fax:218-335-3368
Practice Address - Street 1:425 7TH ST NW
Practice Address - Street 2:CASS LAKE INDIAN HOSPITAL
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3360
Practice Address - Country:US
Practice Address - Phone:218-335-3234
Practice Address - Fax:218-335-3368
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12356122300000X
MI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice