Healthcare Provider Details

I. General information

NPI: 1124641576
Provider Name (Legal Business Name): A LARSEN WELLNESS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 S STATE ST
OREM UT
84097-7026
US

IV. Provider business mailing address

812 S STATE ST
OREM UT
84097-7026
US

V. Phone/Fax

Practice location:
  • Phone: 801-691-7365
  • Fax:
Mailing address:
  • Phone: 801-691-7365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number StateNULL

VIII. Authorized Official

Name: CORBIN COWAN
Title or Position: CEO
Credential:
Phone: 405-229-4052