Provider Demographics
NPI:1306897350
Name:HARRISON, GLENN A (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 WEST FRONT STREET
Mailing Address - Street 2:SUITE 3800
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641
Mailing Address - Country:US
Mailing Address - Phone:276-964-9109
Mailing Address - Fax:276-963-7205
Practice Address - Street 1:2951 WEST FRONT STREET
Practice Address - Street 2:SUITE 3800
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641
Practice Address - Country:US
Practice Address - Phone:276-964-9109
Practice Address - Fax:276-963-7205
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA68361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1350032OtherUMWA
VA059572OtherBCBS
T21388Medicare UPIN