Provider Demographics
NPI:1427102839
Name:JENNINGS-LARSON FAMILY DENTISTRY
Entity type:Organization
Organization Name:JENNINGS-LARSON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-758-5588
Mailing Address - Street 1:1093 HANCOCK RD
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5904
Mailing Address - Country:US
Mailing Address - Phone:928-758-5588
Mailing Address - Fax:928-758-2827
Practice Address - Street 1:1093 HANCOCK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5904
Practice Address - Country:US
Practice Address - Phone:928-758-5588
Practice Address - Fax:928-758-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40261223G0001X
AZ40211223G0001X
AZ48061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty