MEDICARE: MICHAEL JOE LARSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	H-D-1-04331	CO

General Provider Information

NPI Number	:	1093711848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JOE LARSON D.D.S.

Provider Business Mailing Address
First Line	:	27767 WHIRLAWAY TRL
Second Line	:
City	:	EVERGREEN
State	:	CO
Zip	:	80439-6463
Country	:	US
Telephone Number	:	303-674-8229
Fax Number	:

Provider Business Practice Location Address
First Line	:	30940 STAGECOACH BLVD
Second Line	:	STE E250
City	:	EVERGREEN
State	:	CO
Zip	:	80439-7984
Country	:	US
Telephone Number	:	303-674-6777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/08/2007

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