Healthcare Provider Details

I. General information

NPI: 1033407531
Provider Name (Legal Business Name): AARON DAVID LARSEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 WBIRCH
GLENROCK WY
82637
US

IV. Provider business mailing address

PO BOX 2320
GLENROCK WY
82637-2320
US

V. Phone/Fax

Practice location:
  • Phone: 307-436-8770
  • Fax: 307-436-8771
Mailing address:
  • Phone: 307-436-8770
  • Fax: 307-436-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1278
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: