Provider Demographics
NPI:1548630858
Name:VONG, HARRISON (DMD)
Entity type:Individual
Prefix:DR
First Name:HARRISON
Middle Name:
Last Name:VONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701
Mailing Address - Country:US
Mailing Address - Phone:270-872-0347
Mailing Address - Fax:
Practice Address - Street 1:2030 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701
Practice Address - Country:US
Practice Address - Phone:502-935-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY96771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY27556Medicaid