Healthcare Provider Details

I. General information

NPI: 1437776606
Provider Name (Legal Business Name): SAMUEL LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 MARLBOROUGH AVE
SAN DIEGO CA
92116-4727
US

IV. Provider business mailing address

5225 50TH AVE NE UNIT 207
SEATTLE WA
98105-2872
US

V. Phone/Fax

Practice location:
  • Phone: 952-486-9759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number112429
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD160946710
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: