Healthcare Provider Details

I. General information

NPI: 1194322776
Provider Name (Legal Business Name): CHASE LARSEN DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 E 12200 S
DRAPER UT
84020
US

IV. Provider business mailing address

723 E 12200 S STE 101
DRAPER UT
84020-9885
US

V. Phone/Fax

Practice location:
  • Phone: 801-859-5680
  • Fax:
Mailing address:
  • Phone: 801-683-5239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. CHASE MICHAEL LARSEN
Title or Position: MANAGING MEMBER
Credential: DMD
Phone: 801-859-5680