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NPI Code Detail

MEDICARE: HARRISON DENTAL GROUP I LLC

MEDICARE: HARRISON DENTAL GROUP I LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentist
21223G0001XGeneral Practice Dentistry

General Provider Information

NPI Number : 1710580600
Entity Type Code : Organization
Provider Name (Legal Business Name) : HARRISON DENTAL GROUP I LLC
Provider Business Mailing Address
First Line : 6412 WINCHESTER RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46819-1550
Country : US
Telephone Number : 260-747-4747
Fax Number :
Provider Business Practice Location Address
First Line : 6412 WINCHESTER RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46819-1550
Country : US
Telephone Number : 260-747-4747
Fax Number :
Authorized Official
Title or Position : MANAGER
Name : KEITH HARRISON
Credential :
Telephone Number : 260-747-4747
Provider Enumeration Date : 11/21/2020
Last Update Date : 11/21/2020

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Directions to “HARRISON DENTAL GROUP I LLC ” Practice Location

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