Provider Demographics
NPI:1083863088
Name:HARRIS, STACIE LORRAINE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LORRAINE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 S VERONA ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-4037
Mailing Address - Country:US
Mailing Address - Phone:714-761-9447
Mailing Address - Fax:
Practice Address - Street 1:914 S VERONA ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-4037
Practice Address - Country:US
Practice Address - Phone:714-761-9447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist