Provider Demographics
NPI:1194322776
Name:CHASE LARSEN DMD PLLC
Entity type:Organization
Organization Name:CHASE LARSEN DMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHASE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-859-5680
Mailing Address - Street 1:723 E 12200 S STE 101
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9885
Mailing Address - Country:US
Mailing Address - Phone:801-683-5239
Mailing Address - Fax:
Practice Address - Street 1:723 E 12200 S
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020
Practice Address - Country:US
Practice Address - Phone:801-859-5680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty