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General NPI Number Information
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NPI Number | 1245280742
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Entity Type | Organization
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Legal Business Name | LARSEN FAMILY DENTAL S.C.
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 08/23/2013
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Provider Practice Location Address
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Address Line | 215 N. SPRING STREET
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City | BEAVER DAM
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State | WI
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Zip | 53916
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Country | US
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Telephone | 920-885-6066
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Fax | 920-885-6192
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Provider Business Mailing Address
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Address Line | 215 N. SPRING ST.
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City | BEAVER DAM
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State | WI
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Zip | 53916
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Country | US
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Telephone | 920-885-6066
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Fax | 920-885-6192
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ANDREA K LARSEN
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Credential | DDS
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Telephone | 920-885-6066
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 500159515
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License Number State | WI
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