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General NPI Number Information
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NPI Number | 1225759111
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Entity Type | Organization
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Legal Business Name | LAKE HAVASU ORTHODONTICS LLC
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Dates
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Enumeration Date | 09/08/2022
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Last Update Date | 09/08/2022
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Provider Practice Location Address
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Address Line | 2061 SMOKETREE AVE N
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5811
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Country | US
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Telephone | 928-854-4141
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Fax |
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Provider Business Mailing Address
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Address Line | 2212 E ARIS DR
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City | GILBERT
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State | AZ
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Zip | 85298-1205
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Country | US
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Telephone | 253-283-2747
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Fax |
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. ETHAN LARSON
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Credential | DMD, MS
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Telephone | 253-283-2747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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