Healthcare Provider Details

I. General information

NPI: 1275865834
Provider Name (Legal Business Name): GLENN A. HARRISON, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 WEST FRONT STREET SUITE 3800
RICHLANDS VA
24641
US

IV. Provider business mailing address

2951 WEST FRONT STREET SUITE 3800
RICHLANDS VA
24641
US

V. Phone/Fax

Practice location:
  • Phone: 276-964-9109
  • Fax: 276-963-7205
Mailing address:
  • Phone: 276-964-9109
  • Fax: 276-963-7205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6836
License Number StateVA

VIII. Authorized Official

Name: GLENN A. HARRISON
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 276-964-9109