Provider Demographics
NPI:1063197937
Name:HARRELL, MARISSA (RDH, PHDH)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HARRELL
Suffix:
Gender:F
Credentials:RDH, PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12228 MEISENHEIMER AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62049-3004
Mailing Address - Country:US
Mailing Address - Phone:217-556-5014
Mailing Address - Fax:
Practice Address - Street 1:125 W COLUMBIAN BLVD S
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-3021
Practice Address - Country:US
Practice Address - Phone:217-250-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020016072124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist