Individual
DR. MICHAEL ANDREW LARSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
1361 E 16TH ST, BURLEY, ID 83318-2008
(208) 677-5198
(208) 678-2245
Mailing address
794 EASTLAND DR, TWIN FALLS, ID 83301-6856
(208) 734-3312
(208) 734-5036
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
DE10258
WA
1223G0001X
General Practice Dentistry
Primary
D-3993
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5050232
—
WA
05
—
807518200
—
ID
Enumeration date
06/27/2006
Last updated
11/27/2012
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