Healthcare Provider Details

I. General information

NPI: 1356437354
Provider Name (Legal Business Name): MARC LARSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6886 INDIANA AVE STE A
RIVERSIDE CA
92506-4218
US

IV. Provider business mailing address

6886 INDIANA AVE STE A
RIVERSIDE CA
92506-4218
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-6410
  • Fax: 951-680-1755
Mailing address:
  • Phone: 951-686-6410
  • Fax: 951-680-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number47275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: