MEDICARE: B. J. LARSON, D.D.S., P. 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	261QD0000X	Dental Clinic/Center	7195	WA

General Provider Information

NPI Number	:	1215373931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	B. J. LARSON, D.D.S., P. S.

Provider Business Mailing Address
First Line	:	2100 E SECTION ST STE 102
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-9132
Country	:	US
Telephone Number	:	360-428-3565
Fax Number	:	360-428-3593

Provider Business Practice Location Address
First Line	:	2100 E SECTION ST STE 102
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-9132
Country	:	US
Telephone Number	:	360-428-3565
Fax Number	:	360-428-3593

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BERNARD JOHN LARSON
Credential	:	D.D.S.
Telephone Number	:	360-428-3565

Provider Enumeration Date	:	05/21/2013
Last Update Date	:	05/21/2013

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