Healthcare Provider Details

I. General information

NPI: 1346237864
Provider Name (Legal Business Name): LARA INGA LARSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LARA INGA VANDERYACHT DDS

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96TH DENTAL SQUADRON 307 BOATNER AVENUE
EGLIN AFB FL
32542
US

IV. Provider business mailing address

207 GRACIE LANE
NICEVILLE FL
32578
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5846
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: