Provider Demographics
NPI:1114748373
Name:HARLAN, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:HARLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 S PENNSYLVANIA AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-3029
Mailing Address - Country:US
Mailing Address - Phone:806-778-4341
Mailing Address - Fax:
Practice Address - Street 1:218 S MAPLE AVE STE 102
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-3200
Practice Address - Country:US
Practice Address - Phone:724-204-1801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS044856122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist