Provider Demographics
NPI:1538867460
Name:AVELLE GILBERT ORTHO LLC
Entity type:Organization
Organization Name:AVELLE GILBERT ORTHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-283-2747
Mailing Address - Street 1:4365 E PECOS RD STE 136
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4365 E PECOS RD STE 136
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8053
Practice Address - Country:US
Practice Address - Phone:253-283-2747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty