Provider Demographics
NPI:1134339385
Name:MOUNTAIN PERIO
Entity type:Organization
Organization Name:MOUNTAIN PERIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:828-693-7533
Mailing Address - Street 1:200 BEVERLY HANKS CTR
Mailing Address - Street 2:SUITE B
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28792-2301
Mailing Address - Country:US
Mailing Address - Phone:828-693-7533
Mailing Address - Fax:828-693-5494
Practice Address - Street 1:200 BEVERLY HANKS CTR
Practice Address - Street 2:SUITE B
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-2301
Practice Address - Country:US
Practice Address - Phone:828-693-7533
Practice Address - Fax:828-693-5494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC48091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty