Provider Demographics
NPI:1871691436
Name:LARSEN, MATT GLEN (DMD)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:GLEN
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 RIMROCK RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-0700
Mailing Address - Country:US
Mailing Address - Phone:406-245-7026
Mailing Address - Fax:406-238-0141
Practice Address - Street 1:1690 RIMROCK RD
Practice Address - Street 2:SUITE F
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-0700
Practice Address - Country:US
Practice Address - Phone:406-245-7026
Practice Address - Fax:406-238-0141
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice