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General NPI Number Information
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NPI Number | 1417055062
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Entity Type | Organization
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Legal Business Name | DONALD E LARSON DMD PC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 700 E STATE ST SUITE 100
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City | EAGLE
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State | ID
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Zip | 83616
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Country | US
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Telephone | 208-939-3500
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Fax | 208-939-3837
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Provider Business Mailing Address
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Address Line | 5919 N LILYBROOK PL
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City | BOISE
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State | ID
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Zip | 83713
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Country | US
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Telephone | 208-939-1570
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Fax | 208-939-1570
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DONALD E LARSON
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Credential | DMD
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Telephone | 208-939-1570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D3551
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License Number State | ID
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