Provider Demographics
NPI:1275263634
Name:HARRIED, AMBER LASHA
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LASHA
Last Name:HARRIED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-5366
Mailing Address - Country:US
Mailing Address - Phone:718-406-5693
Mailing Address - Fax:
Practice Address - Street 1:110 US 61
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120
Practice Address - Country:US
Practice Address - Phone:718-406-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4288-22122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist