Healthcare Provider Details

I. General information

NPI: 1689747917
Provider Name (Legal Business Name): LOUIE V. HARRISON, III DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 TYLER HOLMES DR
WINONA MS
38967-1522
US

IV. Provider business mailing address

PO BOX 761
WINONA MS
38967-0761
US

V. Phone/Fax

Practice location:
  • Phone: 662-283-4722
  • Fax: 662-283-2588
Mailing address:
  • Phone: 662-283-4722
  • Fax: 662-283-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2278-86
License Number StateMS

VIII. Authorized Official

Name: DR. LOUIE VARDIMAN HARRISON III
Title or Position: OWNER
Credential: DMD
Phone: 662-283-4722