Provider Demographics
NPI:1407938673
Name:HARRISON, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:S
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:755 W CARMEL DR
Mailing Address - Street 2:STE 215
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5878
Mailing Address - Country:US
Mailing Address - Phone:317-249-1001
Mailing Address - Fax:317-249-1003
Practice Address - Street 1:755 W CARMEL DR
Practice Address - Street 2:STE 215
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5878
Practice Address - Country:US
Practice Address - Phone:317-249-1001
Practice Address - Fax:317-249-1003
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009566A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist