Provider Demographics
NPI:1770249757
Name:DRS. HARRISON & RYAN - PETERS CREEK DENTISTRY, PLLC
Entity type:Organization
Organization Name:DRS. HARRISON & RYAN - PETERS CREEK DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-859-0444
Mailing Address - Street 1:2945 PETERS CREEK RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-3513
Mailing Address - Country:US
Mailing Address - Phone:540-562-4001
Mailing Address - Fax:
Practice Address - Street 1:2945 PETERS CREEK RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-3513
Practice Address - Country:US
Practice Address - Phone:540-562-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty