MEDICARE: DR. MARK LARSEN DMD

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	7536	AZ

General Provider Information

NPI Number	:	1417110016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK LARSEN DMD

Provider Business Mailing Address
First Line	:	12979 N DESERT OLIVE DR
Second Line	:
City	:	ORO VALLEY
State	:	AZ
Zip	:	85755-1860
Country	:	US
Telephone Number	:	520-344-9285
Fax Number	:

Provider Business Practice Location Address
First Line	:	3773 W INA RD STE 180
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741-2292
Country	:	US
Telephone Number	:	520-579-8166
Fax Number	:

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

Provider Enumeration Date	:	07/03/2008
Last Update Date	:	07/03/2008

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