Provider Demographics
NPI:1548263445
Name:HARRISON, RICK KENNETH (DMD)
Entity type:Individual
Prefix:DR
First Name:RICK
Middle Name:KENNETH
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:K
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD,PA
Mailing Address - Street 1:227 11TH AVE S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6529
Mailing Address - Country:US
Mailing Address - Phone:904-241-4237
Mailing Address - Fax:
Practice Address - Street 1:227 11TH AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6529
Practice Address - Country:US
Practice Address - Phone:904-241-4237
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN119911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice