MEDICARE: SAMUEL LARSEN

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	126800000X	Dental Assistant	D160946710	WA
2	122300000X	Dentist	112429	CA

General Provider Information

NPI Number	:	1437776606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL LARSEN

Provider Business Mailing Address
First Line	:	5225 50TH AVE NE UNIT 207
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-2872
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4403 MARLBOROUGH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-4727
Country	:	US
Telephone Number	:	952-486-9759
Fax Number	:

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

Provider Enumeration Date	:	07/02/2020
Last Update Date	:	02/06/2026

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Directions to “ SAMUEL LARSEN ” Practice Location

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