Provider Demographics
NPI:1083090567
Name:HARRIS, KHEALYNN FERNELIUS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KHEALYNN
Middle Name:FERNELIUS
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CULLENS ST NW
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9417
Mailing Address - Country:US
Mailing Address - Phone:801-857-8001
Mailing Address - Fax:
Practice Address - Street 1:202 CULLENS ST NW
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-9417
Practice Address - Country:US
Practice Address - Phone:801-857-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE605866031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice