Provider Demographics
NPI:1861608564
Name:LARSON, DANA DIANE (DDS)
Entity type:Individual
Prefix:MS
First Name:DANA
Middle Name:DIANE
Last Name:LARSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-357-6220
Mailing Address - Fax:360-352-5412
Practice Address - Street 1:1212 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-357-6220
Practice Address - Fax:360-352-5412
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA74551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA831896OtherUNITED CONCORDIA
WA5356001OtherDSHS
WA9590OtherWASHINGTON DENTAL SERVICE
WA134017OtherL AND I