Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DE00007407 | WA |
NPI | 1013014471 |
---|---|
Provider Name | Russell M Larsen |
First Address | Montesano, WA 98563-3706 |
Second Address | Montesano, WA 98563-3706 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5032016 | (05) | WA |