Provider Demographics
NPI:1093977811
Name:HARRIS, RANDALL D (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 ROUTE 12
Mailing Address - Street 2:P.O. BOX 396
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1800
Mailing Address - Country:US
Mailing Address - Phone:860-464-7204
Mailing Address - Fax:860-464-0186
Practice Address - Street 1:1527 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1800
Practice Address - Country:US
Practice Address - Phone:860-464-7204
Practice Address - Fax:860-464-0186
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0048141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice