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NPI Code Detail

MEDICARE: MR. CORY JOHN LARSON DDS

MEDICARE: MR. CORY JOHN LARSON DDS
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
11223G0001XGeneral Practice Dentistry12212MN

General Provider Information

NPI Number : 1487762548
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. CORY JOHN LARSON DDS
Provider Business Mailing Address
First Line : 1632 WASHINGTON ST NE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55413-1336
Country : US
Telephone Number : 612-789-2853
Fax Number : 612-789-2853
Provider Business Practice Location Address
First Line : 1632 WASHINGTON ST NE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55413-1336
Country : US
Telephone Number : 612-789-2853
Fax Number : 612-789-9413
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/29/2006
Last Update Date : 07/08/2007

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