Healthcare Provider Details

I. General information

NPI: 1558294611
Provider Name (Legal Business Name): JEFFERY BROUGHAM LARSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 ADMIRAL TAUSSIG BLVD
NORFOLK VA
23511-2803
US

IV. Provider business mailing address

8150 SHORE DR APT 326
NORFOLK VA
23518-2365
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-8635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDENT.DE.70118772
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: