Healthcare Provider Details

I. General information

NPI: 1669392486
Provider Name (Legal Business Name): HARRISON DETROY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E MAIN ST STE 130
ALHAMBRA CA
91801-3580
US

IV. Provider business mailing address

2903 BELLEVUE AVE
LOS ANGELES CA
90026-3754
US

V. Phone/Fax

Practice location:
  • Phone: 626-586-3251
  • Fax:
Mailing address:
  • Phone: 847-571-4446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113018
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: