=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558294611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFERY BROUGHAM LARSEN DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2026
-----------------------------------------------------
Last Update Date | 06/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1647 ADMIRAL TAUSSIG BLVD
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23511-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-445-8815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13022 26TH AVE S
-----------------------------------------------------
City | SEATAC
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98168-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DENT.DE.70118772
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------