MEDICARE: DR. JON PHILIP 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
1	122300000X	Dentist	30-01-3524	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912908542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON PHILIP LARSON DDS

Provider Business Mailing Address
First Line	:	497 CINCINNATI BATAVIA PIKE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45244-4212
Country	:	US
Telephone Number	:	513-528-1223
Fax Number	:	513-328-6123

Provider Business Practice Location Address
First Line	:	497 CINCINNATI BATAVIA PIKE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45244-4212
Country	:	US
Telephone Number	:	513-528-1223
Fax Number	:	513-328-6123

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

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	07/08/2007

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