Provider Demographics
NPI:1194849497
Name:HARRIS, GARY WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
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 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:307 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MO
Practice Address - Zip Code:65281-1037
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:660-388-6870
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0141641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO404040602Medicaid