Provider Demographics
NPI:1033276357
Name:LARSON, STEPHEN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:LARSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 CINCINNATI BATAVIA PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-0249
Mailing Address - Country:US
Mailing Address - Phone:513-528-1223
Mailing Address - Fax:
Practice Address - Street 1:612 ROCKDALE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-2919
Practice Address - Country:US
Practice Address - Phone:513-352-4072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300224111223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2679981Medicaid