# LARSEN DENTAL CARE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104061449
- **Authorized official:** DR. BRYCE R LARSEN D.M.D. (DENTIST OWNER)
- **Authorized official phone:** (208) 233-7007

## Contact information

- **Practice address:** 950 HOSPITAL WAY, SUITE B, POCATELLO, ID 83201-2789
- **Practice address phone:** (208) 233-7007
- **Practice address fax:** (208) 233-2512
- **Mailing address:** 950 HOSPITAL WAY, SUITE B, POCATELLO, ID 83201-2789
- **Mailing address phone:** (208) 233-7007
- **Mailing address fax:** (208) 233-2512

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | D-1599 | ID | — |
| 1223G0001X | General Practice Dentistry | D-3894 | ID | Yes |

## Other

- **Enumeration date:** 12/15/2008
- **Last updated:** 12/15/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 8072105 | — | ID |