Provider Demographics
NPI:1265674055
Name:HARRIS, CONRAD WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
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 1:4000 14TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5524
Mailing Address - Country:US
Mailing Address - Phone:202-726-3760
Mailing Address - Fax:202-726-3760
Practice Address - Street 1:4000 14TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5524
Practice Address - Country:US
Practice Address - Phone:202-726-3760
Practice Address - Fax:202-726-3760
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN47401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice