Healthcare Provider Details

I. General information

NPI: 1598890063
Provider Name (Legal Business Name): TODD S LARSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8915 S 700 E STE 103
SANDY UT
84070-2421
US

IV. Provider business mailing address

8915 S 700 E STE 103
SANDY UT
84070-2421
US

V. Phone/Fax

Practice location:
  • Phone: 801-562-2147
  • Fax: 801-569-1795
Mailing address:
  • Phone: 801-562-2147
  • Fax: 801-569-1795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number360817-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN014721
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: