Provider Demographics
NPI:1417038977
Name:HARRISON, TINA F (DMD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:F
Last Name:HARRISON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25043 HIGHWAY 15
Mailing Address - Street 2:P.O. BOX 276
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365
Mailing Address - Country:US
Mailing Address - Phone:601-774-9949
Mailing Address - Fax:601-774-9955
Practice Address - Street 1:25043 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-8577
Practice Address - Country:US
Practice Address - Phone:601-774-9949
Practice Address - Fax:601-774-9955
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3001-971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660263Medicaid