Provider Demographics
NPI:1912908542
Name:LARSON, JON PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:PHILIP
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 1:497 CINCINNATI BATAVIA PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-4212
Mailing Address - Country:US
Mailing Address - Phone:513-528-1223
Mailing Address - Fax:513-328-6123
Practice Address - Street 1:497 CINCINNATI BATAVIA PIKE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-4212
Practice Address - Country:US
Practice Address - Phone:513-528-1223
Practice Address - Fax:513-328-6123
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-3524122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211765Medicaid