Provider Demographics
NPI:1720209000
Name:HARRISON, DAVID K (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:K
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 1:6412 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-1550
Mailing Address - Country:US
Mailing Address - Phone:260-747-4747
Mailing Address - Fax:260-747-4749
Practice Address - Street 1:6412 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46819-1550
Practice Address - Country:US
Practice Address - Phone:260-747-4747
Practice Address - Fax:260-747-4749
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120085771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100079930Medicaid