Provider Demographics
NPI:1720106198
Name:LARSON, GREG D (DDS)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:D
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 1:232 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1555
Mailing Address - Country:US
Mailing Address - Phone:415-203-9908
Mailing Address - Fax:
Practice Address - Street 1:3111 SPRINGBANK LN STE F1
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3372
Practice Address - Country:US
Practice Address - Phone:704-220-1930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA466321223G0001X
NC124301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice