Provider Demographics
NPI:1275865834
Name:GLENN A. HARRISON, P.C.
Entity Type:Organization
Organization Name:GLENN A. HARRISON, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-964-9109
Mailing Address - Street 1:2951 WEST FRONT STREET
Mailing Address - Street 2:SUITE 3800
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641
Mailing Address - Country:US
Mailing Address - Phone:276-964-9109
Mailing Address - Fax:276-963-7205
Practice Address - Street 1:2951 WEST FRONT STREET
Practice Address - Street 2:SUITE 3800
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641
Practice Address - Country:US
Practice Address - Phone:276-964-9109
Practice Address - Fax:276-963-7205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA68361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008000026Medicaid
T21388Medicare UPIN
VA008000026Medicaid