Individual
RUSSELL M LARSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
208 E BROADWAY AVE, MONTESANO, WA 98563-3706
(360) 249-3151
(360) 249-5129
Mailing address
208 E BROADWAY AVE, MONTESANO, WA 98563-3706
(360) 249-3151
(360) 249-5129
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DE00007407
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5032016
—
WA
Enumeration date
09/20/2006
Last updated
07/09/2007
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