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General NPI Number Information
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NPI Number | 1295825602
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Entity Type | Individual
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Provider Name | JERRY R HARRISON DMD
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Gender | Male
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Dates
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Enumeration Date | 10/14/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2490 N WATER ST SUITE 11
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City | DECATUR
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State | IL
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Zip | 62526-4251
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Country | US
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Telephone | 217-875-1677
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Fax | 217-875-1834
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Provider Business Mailing Address
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Address Line | 2490 N WATER ST SUITE 11
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City | DECATUR
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State | IL
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Zip | 62526-4251
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Country | US
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Telephone | 217-875-1677
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Fax | 217-875-1834
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 19A15654
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License Number State | IL
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