Healthcare Provider Details

I. General information

NPI: 1447435656
Provider Name (Legal Business Name): EDWIN VERNOR LARSON JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 STATE ST
MONTPELIER VT
05602-3361
US

IV. Provider business mailing address

153 STATE ST
MONTPELIER VT
05602-3361
US

V. Phone/Fax

Practice location:
  • Phone: 802-229-4225
  • Fax: 802-229-9944
Mailing address:
  • Phone: 802-229-4225
  • Fax: 802-229-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number016-0001208
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: