Healthcare Provider Details

I. General information

NPI: 1619073061
Provider Name (Legal Business Name): LARSEN, DDS-BLANCHARD, DMD, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E BROADWAY AVE
MONTESANO WA
98563-3706
US

IV. Provider business mailing address

208 E BROADWAY AVE
MONTESANO WA
98563-3706
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-3151
  • Fax: 360-249-5129
Mailing address:
  • Phone: 360-249-3151
  • Fax: 360-249-5129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00007407
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00008166
License Number StateWA

VIII. Authorized Official

Name: RUSSELL M LARSEN
Title or Position: CO-OWNER
Credential: DDS
Phone: 360-249-3151