Provider Demographics
NPI:1841974755
Name:LARSON, IAN JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:JAMES
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 RADLEY DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-8074
Mailing Address - Country:US
Mailing Address - Phone:610-357-3606
Mailing Address - Fax:
Practice Address - Street 1:616 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-9706
Practice Address - Country:US
Practice Address - Phone:276-525-4487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014185011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice