Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D010330 | AZ |
NPI | 1003474966 |
---|---|
Provider Name | Tanner Christopher Larson |
First Address | Bullhead City, AZ 86442-5904 |
Second Address | Bullhead City, AZ 86442-5904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2019 |
Last Update Date | 04/06/2019 |