Provider Demographics
NPI:1548314958
Name:LARSON, KYLE MARSH (DDS)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MARSH
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 1:1511 SUNRISE CIR
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-4211
Mailing Address - Country:US
Mailing Address - Phone:702-293-3767
Mailing Address - Fax:
Practice Address - Street 1:1093 HANCOCK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5904
Practice Address - Country:US
Practice Address - Phone:928-758-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48061223G0001X
NV31901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice