=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053618801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B.G.HARRISON D.D.S. AND ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2011
-----------------------------------------------------
Last Update Date | 02/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1408 SKIBO RD.
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-922-9989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3805 DOONVALLEY DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28306-7564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-922-9989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATION MANAGER
-----------------------------------------------------
Name | MRS. JASMINKA JELIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-922-9989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------