Provider Demographics
NPI:1275709610
Name:DONELSON, HARLO LEE (DDS)
Entity Type:Individual
Prefix:
First Name:HARLO
Middle Name:LEE
Last Name:DONELSON
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 1:125 S MAIN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:MO
Mailing Address - Zip Code:63555-1423
Mailing Address - Country:US
Mailing Address - Phone:660-465-7770
Mailing Address - Fax:660-465-7770
Practice Address - Street 1:125 S MAIN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-1423
Practice Address - Country:US
Practice Address - Phone:660-465-7770
Practice Address - Fax:660-465-7770
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0988022Medicaid