Healthcare Provider Details

I. General information

NPI: 1609208826
Provider Name (Legal Business Name): CHAD EVANS LARSON D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 BROADWAY AVE S STE A
ROCHESTER MN
55904-7973
US

IV. Provider business mailing address

1705 BROADWAY AVE S STE A
ROCHESTER MN
55904-7973
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-4427
  • Fax: 507-288-8497
Mailing address:
  • Phone: 507-288-4427
  • Fax: 507-288-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13231
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: