MEDICARE: HARRISON DENTAL GROUP III LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1083217970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRISON DENTAL GROUP III LLC

Provider Business Mailing Address
First Line	:	6412 WINCHESTER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46819-1550
Country	:	US
Telephone Number	:	260-747-4747
Fax Number	:

Provider Business Practice Location Address
First Line	:	10506 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1235
Country	:	US
Telephone Number	:	260-747-4747
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	KEITH HARRISON
Credential	:
Telephone Number	:	260-747-4747

Provider Enumeration Date	:	11/21/2020
Last Update Date	:	11/21/2020

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