Healthcare Provider Details

I. General information

NPI: 1912908542
Provider Name (Legal Business Name): JON PHILIP LARSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 CINCINNATI BATAVIA PIKE
CINCINNATI OH
45244-4212
US

IV. Provider business mailing address

497 CINCINNATI BATAVIA PIKE
CINCINNATI OH
45244-4212
US

V. Phone/Fax

Practice location:
  • Phone: 513-528-1223
  • Fax: 513-328-6123
Mailing address:
  • Phone: 513-528-1223
  • Fax: 513-328-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-01-3524
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: