Provider Demographics
NPI:1023432200
Name:HARRISON DENTAL, LLC
Entity type:Organization
Organization Name:HARRISON DENTAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUNGATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-398-0066
Mailing Address - Street 1:225 S HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-2159
Mailing Address - Country:US
Mailing Address - Phone:317-398-0066
Mailing Address - Fax:
Practice Address - Street 1:225 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-2159
Practice Address - Country:US
Practice Address - Phone:317-398-0066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009085A1223G0001X
IN12011411A1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12011411AOtherDENTAL LICENSE
IN1487775144OtherNPI TYPE 1
IN1376687509OtherNPI TYPE 1
IN12009085AOtherDENTAL LICENSE