Healthcare Provider Details

I. General information

NPI: 1962585398
Provider Name (Legal Business Name): HARRISON DAI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8049 CLEVELAND PLACE
MERRILLVILLE IN
46410
US

IV. Provider business mailing address

8049 CLEVELAND PLACE
MERRILLVILLE IN
46410
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-1851
  • Fax: 219-738-2275
Mailing address:
  • Phone: 219-738-1851
  • Fax: 219-738-2275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12009098A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number19016199
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: