Healthcare Provider Details

I. General information

NPI: 1093905788
Provider Name (Legal Business Name): PATRICK RAY HARRISON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2007
Last Update Date: 07/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 NIAGARA AVE
ASTORIA OR
97103-5119
US

IV. Provider business mailing address

762 NIAGARA AVE
ASTORIA OR
97103-5119
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-7413
  • Fax: 503-325-5873
Mailing address:
  • Phone: 503-325-7413
  • Fax: 503-325-5873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD7511
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: