Healthcare Provider Details

I. General information

NPI: 1508797119
Provider Name (Legal Business Name): SAMUEL EMMANUEL LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 7TH ST E
SAINT PAUL MN
55119-3419
US

IV. Provider business mailing address

11585 QUAIL AVE N
STILLWATER MN
55082-4791
US

V. Phone/Fax

Practice location:
  • Phone: 651-735-0595
  • Fax:
Mailing address:
  • Phone: 651-434-7247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD15427
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: