Provider Demographics
NPI:1073684825
Name:HARRISON, MATTHEW BURKE (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BURKE
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-4235
Mailing Address - Country:US
Mailing Address - Phone:479-636-1194
Mailing Address - Fax:479-636-8549
Practice Address - Street 1:1107 W ELM ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4235
Practice Address - Country:US
Practice Address - Phone:479-636-1194
Practice Address - Fax:479-636-8549
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice