MEDICARE: DR. ERIC A. LARSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	334445-9921	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80012476	OTHER	UT	TIN #

General Provider Information

NPI Number	:	1417081308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC A. LARSON D.D.S.

Provider Business Mailing Address
First Line	:	928 EAST 100 SOUTH
Second Line	:	STE #B
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-8410
Country	:	US
Telephone Number	:	801-355-4733
Fax Number	:	801-322-0629

Provider Business Practice Location Address
First Line	:	928 E 100 S
Second Line	:	STE #B
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1455
Country	:	US
Telephone Number	:	801-355-4733
Fax Number	:	801-322-0629

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/08/2007

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