Provider Demographics
NPI:1053005934
Name:LARSON, REBECCA (DDS)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
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 1:13833 LINDBLOM RD
Mailing Address - Street 2:
Mailing Address - City:BARAGA
Mailing Address - State:MI
Mailing Address - Zip Code:49908-9154
Mailing Address - Country:US
Mailing Address - Phone:906-231-1648
Mailing Address - Fax:
Practice Address - Street 1:N5241 US HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969-5115
Practice Address - Country:US
Practice Address - Phone:906-358-4931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016016761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice