# DONALD E LARSON DMD PC

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

## Provider details

- **NPI number:** 1417055062
- **Authorized official:** DR. DONALD E LARSON DMD (PRESIDENT)
- **Authorized official phone:** (208) 939-1570

## Contact information

- **Practice address:** 700 E STATE ST, SUITE 100, EAGLE, ID 83616
- **Practice address phone:** (208) 939-3500
- **Practice address fax:** (208) 939-3837
- **Mailing address:** 5919 N LILYBROOK PL, BOISE, ID 83713
- **Mailing address phone:** (208) 939-1570
- **Mailing address fax:** (208) 939-1570

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | D3551 | ID | Yes |

## Other

- **Enumeration date:** 09/20/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 8061442 | — | ID |
| 01 | — | CS9245 | ID STATE BOARD OF PHARM | ID |