Provider Demographics
NPI:1356607600
Name:HARRIOTT, KERISA (DMD)
Entity type:Individual
Prefix:DR
First Name:KERISA
Middle Name:
Last Name:HARRIOTT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 JUSTINE WAY SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2839
Mailing Address - Country:US
Mailing Address - Phone:718-764-7479
Mailing Address - Fax:
Practice Address - Street 1:1111 JOHNSON FERRY RD # 10
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2181
Practice Address - Country:US
Practice Address - Phone:718-764-7479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0568871223X0400X
390200000X
GADN1230041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program