Provider Demographics
NPI:1669361150
Name:HARRISON, AVERY MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:AVERY
Middle Name:MICHAEL
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4814 OUTER LOOP
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3302
Mailing Address - Country:US
Mailing Address - Phone:502-546-6272
Mailing Address - Fax:
Practice Address - Street 1:4814 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3302
Practice Address - Country:US
Practice Address - Phone:502-546-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY114301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice