Provider Demographics
NPI:1053591495
Name:W.BRENT LARSEN, D.D.S., P.A.
Entity type:Organization
Organization Name:W.BRENT LARSEN, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:W. BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-843-9306
Mailing Address - Street 1:3 TEMPLETON DR
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3821
Mailing Address - Country:US
Mailing Address - Phone:501-843-9306
Mailing Address - Fax:501-843-4251
Practice Address - Street 1:3 TEMPLETON DR
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3821
Practice Address - Country:US
Practice Address - Phone:501-843-9306
Practice Address - Fax:501-843-4251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2976261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental