=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598944340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANCE HERSCHEL HARRISON JR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2007
-----------------------------------------------------
Last Update Date | 03/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7725 LAKE WORTH RD STE 7729
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33467-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-359-6483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 813 PARK DR
-----------------------------------------------------
City | GOODLETTSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37072-3147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-388-5819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 053622
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8737
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN27515
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------