Provider Demographics
NPI:1306998414
Name:LARSON, JAMES JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JAY
Last Name:LARSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAKE STREET W
Mailing Address - Street 2:SUITE 220
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391
Mailing Address - Country:US
Mailing Address - Phone:952-475-2464
Mailing Address - Fax:952-475-2664
Practice Address - Street 1:101 LAKE STREET W
Practice Address - Street 2:SUITE 220
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-475-2464
Practice Address - Fax:952-475-2664
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist