# LARSEN, DDS-BLANCHARD, DMD, PS

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** Broadway Dental Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619073061
- **Authorized official:** RUSSELL M LARSEN DDS (CO-OWNER)
- **Authorized official phone:** (360) 249-3151

## Contact information

- **Practice address:** 208 E BROADWAY AVE, MONTESANO, WA 98563-3706
- **Practice address phone:** (360) 249-3151
- **Practice address fax:** (360) 249-5129
- **Mailing address:** 208 E BROADWAY AVE, MONTESANO, WA 98563-3706
- **Mailing address phone:** (360) 249-3151
- **Mailing address fax:** (360) 249-5129

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | DE00007407 | WA | — |
| 122300000X | Dentist | DE00008166 | WA | Yes |

## Other

- **Enumeration date:** 09/15/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 5306808 | — | WA |