Provider Demographics
NPI:1629539697
Name:HARRISON, KYLE A (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:A
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 1:1425 PENN CIRCLE DR UNIT 207
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-6116
Mailing Address - Country:US
Mailing Address - Phone:765-366-5686
Mailing Address - Fax:
Practice Address - Street 1:506 CORDA BLVD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-4935
Practice Address - Country:US
Practice Address - Phone:765-362-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013418A1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice