Provider Demographics
NPI:1689747917
Name:LOUIE V. HARRISON, III DMD PLLC
Entity Type:Organization
Organization Name:LOUIE V. HARRISON, III DMD PLLC
Other - Org Name:LOUIE V HARRISON III DMD PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIE
Authorized Official - Middle Name:VARDIMAN
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-283-4722
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-0761
Mailing Address - Country:US
Mailing Address - Phone:662-283-4722
Mailing Address - Fax:662-283-2588
Practice Address - Street 1:412 TYLER HOLMES DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1522
Practice Address - Country:US
Practice Address - Phone:662-283-4722
Practice Address - Fax:662-283-2588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2278-861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2278-86OtherDENTAL LICENSE #
MS00060241Medicaid