Healthcare Provider Details

I. General information

NPI: 1811105299
Provider Name (Legal Business Name): MICKEY C. HARRISON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3974 KARL RD
COLUMBUS OH
43224-5221
US

IV. Provider business mailing address

3974 KARL RD
COLUMBUS OH
43224-5221
US

V. Phone/Fax

Practice location:
  • Phone: 614-267-5000
  • Fax: 614-267-0541
Mailing address:
  • Phone: 614-267-5000
  • Fax: 614-267-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21189
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: