Provider Demographics
NPI:1710144225
Name:HARBISON, CHARLES EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWIN
Last Name:HARBISON
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 1:730 GOODMAN RD E
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9530
Mailing Address - Country:US
Mailing Address - Phone:662-349-2351
Mailing Address - Fax:662-349-2416
Practice Address - Street 1:730 GOODMAN RD E
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-349-2351
Practice Address - Fax:662-349-2416
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1231-681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice