Provider Demographics
NPI:1558418897
Name:DR. RONNIE HARRISON P.A.
Entity Type:Organization
Organization Name:DR. RONNIE HARRISON P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-947-9530
Mailing Address - Street 1:PO BOX 798
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-0798
Mailing Address - Country:US
Mailing Address - Phone:601-947-9530
Mailing Address - Fax:601-947-9595
Practice Address - Street 1:13 PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452
Practice Address - Country:US
Practice Address - Phone:601-947-9530
Practice Address - Fax:601-947-9595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05237756Medicaid
MS00660149Medicaid