Provider Demographics
NPI:1609894963
Name:HARRISON, STEPHEN PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:HARRISON
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 1:781 ROZA DR
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9351
Mailing Address - Country:US
Mailing Address - Phone:509-829-5466
Mailing Address - Fax:509-829-5038
Practice Address - Street 1:781 ROZA DR
Practice Address - Street 2:
Practice Address - City:ZILLAH
Practice Address - State:WA
Practice Address - Zip Code:98953-9351
Practice Address - Country:US
Practice Address - Phone:509-829-5466
Practice Address - Fax:509-829-5038
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000059351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5032552Medicaid
WA911993371 0001OtherELECTRONIC ID NUMBER