| NPI | 1104061449 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRYCE R LARSEN Dentist Owner 208-233-7007 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ID D-3894) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: ID D-1599) |
| Enumeration Date | 2008-12-15 |
| Last Update Date | 2008-12-15 |