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General NPI Number Information
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NPI Number | 1619073061
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Entity Type | Organization
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Legal Business Name | LARSEN, DDS-BLANCHARD, DMD, PS
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 208 E BROADWAY AVE
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City | MONTESANO
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State | WA
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Zip | 98563-3706
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Country | US
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Telephone | 360-249-3151
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Fax | 360-249-5129
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Provider Business Mailing Address
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Address Line | 208 E BROADWAY AVE
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City | MONTESANO
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State | WA
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Zip | 98563-3706
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Country | US
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Telephone | 360-249-3151
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Fax | 360-249-5129
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Authorized Official
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Title or Position | CO-OWNER
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Name | RUSSELL M LARSEN
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Credential | DDS
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Telephone | 360-249-3151
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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 | DE00007407
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DE00008166
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License Number State | WA
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