Basic Information
| Provider Information | |||||||||
| NPI: | 1336126697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPARTMENT OF THE ARMY DENTAL ACTIVITY STOP | ||||||||
| Address2: | 2817 REILLY RD, MCDS-NA-B | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103965610 | ||||||||
| FaxNumber: | 9103967017 | ||||||||
| Practice Location | |||||||||
| Address1: | DEPARTMENT OF THE ARMY DENTAL ACTIVITY STOP | ||||||||
| Address2: | 2817 REILLY RD, MCDS-NA-B | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103965610 | ||||||||
| FaxNumber: | 9103967017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 6283 | NE | Y | Dental Providers | Dentist | General Practice |
No ID Information.