Provider Demographics
NPI:1255725297
Name:HARRELL DENTAL
Entity type:Organization
Organization Name:HARRELL DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MBA
Authorized Official - Phone:307-635-1197
Mailing Address - Street 1:121 W CARLSON ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4044
Mailing Address - Country:US
Mailing Address - Phone:307-635-1197
Mailing Address - Fax:
Practice Address - Street 1:121 W CARLSON ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4044
Practice Address - Country:US
Practice Address - Phone:307-635-1197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1355261QD0000X
WY1173261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental