LARSEN, D.D.S. BLANCHARD, D.M.D., P.S.

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Company Details

Legal Name:	LARSEN, D.D.S. BLANCHARD, D.M.D., P.S.
Jurisdiction:	WASHINGTON
Entity Type:	WA PROFESSIONAL SERVICE CORPORATION
Category:	DOMESTIC ENTITY
Status:	Voluntarily Dissolved
Formation/ Registration Date:	October 29th 1975
Date of Dissolution:	October 4th 2019
Expiration date:	31 Oct 2019
UBI Number:	600 178 142
ZIP code:	98563
City:	Montesano
County:	GRAYS HARBOR
Home State:	WASHINGTON
Principal Office Street Address:	32 ALDERGROVE DR, MONTESANO, WA, 98563-9608, UNITED STATES
Principal Office Mailing Address:	PO BOX 463, MONTESANO, WA, 98563-0463, UNITED STATES

Contact Details

E-Mail:	LORIBROADWAYDENTAL@GMAIL.COM
Phone Number:	+1 360-470-9941

Nature of Business

Health Care, Social Assistance & Service Organization

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Registered Agent Information

Name	Role	Address
LORI BLANCHARD	Registered Agent	32 ALDERGROVE DR, MONTESANO, WA, 98563-9608, UNITED STATES

Key Officers & Management

Name	Role
RUSSELL LARSEN	Governing Person
LORI BLANCHARD	Governing Person
GREG BLANCHARD	Governing Person
KAY LARSEN	Governing Person

National Provider Identifier

NPI Number:

1619073061

Link:

View on NPI website

Authorized Person:

Name:

RUSSELL M LARSEN

Role:

CO-OWNER

Phone:

3602493151

Taxonomy:

Selected Taxonomy:

122300000X - Dentist

Is Primary:

No

Selected Taxonomy:

122300000X - Dentist

Is Primary:

Yes

Contacts:

Phone:

+1 360-249-3151

Fax:

3602495129

Form 5500 Series

Employer Identification Number (EIN):

910946974

Plan Year:

2017

Number Of Participants:

15

Plan Name:

401(K)

Sponsor's telephone number:

3602493151

File:

Plan Year:

2017

Number Of Participants:

13

Sponsor's telephone number:

3602493151

File:

Plan Year:

2016

Number Of Participants:

14

Plan Name:

401(K)

Sponsor's telephone number:

3602493151

File:

Plan Administrator / Signatory:

RUSSELL M LARSEN(Plan administrator)

Plan Year:

2015

Number Of Participants:

15

Plan Name:

401(K)

Sponsor's telephone number:

3602493151

File:

Plan Administrator / Signatory:

RUSSELL M LARSEN(Plan administrator)

Plan Year:

2014

Number Of Participants:

14

Plan Name:

401(K)

Sponsor's telephone number:

3602493151

File:

Plan Administrator / Signatory:

RUSSELL M LARSEN(Plan administrator) RUSSELL M LARSEN(Employer/plan sponsor)

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