Provider Demographics
NPI:1912024696
Name:HARRISON, JOHN B (DDS,MSC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DDS,MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4408
Mailing Address - Country:US
Mailing Address - Phone:727-822-3156
Mailing Address - Fax:727-822-3405
Practice Address - Street 1:545 4TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4408
Practice Address - Country:US
Practice Address - Phone:727-822-3156
Practice Address - Fax:727-822-3405
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL37701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics