Provider Demographics
NPI:1295090975
Name:HARRISON, ANNE KALLISTA (DDS)
Entity type:Individual
Prefix:DR
First Name:ANNE
Middle Name:KALLISTA
Last Name:HARRISON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ANNE
Other - Middle Name:KALLISTA
Other - Last Name:JOHNSNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1922 RIO GRANDE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-2524
Mailing Address - Country:US
Mailing Address - Phone:505-504-4156
Mailing Address - Fax:
Practice Address - Street 1:8501 CANDELARIA RD NE
Practice Address - Street 2:SUITE C1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1034
Practice Address - Country:US
Practice Address - Phone:505-298-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD36961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice