Provider Demographics
NPI:1225117989
Name:HARRIS, KIM (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:BOTTOMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:7755 WALKER CUP DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6225 W 56TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-7603
Practice Address - Country:US
Practice Address - Phone:317-293-3300
Practice Address - Fax:317-293-3437
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120095501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200141150BMedicaid
IN978759OtherUNITED CONCORDIA NUMBER