Provider Demographics
NPI:1275523987
Name:HARRIS, DAVID GLENN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLENN
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 1:1100 SONOMA AVE
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8901
Mailing Address - Country:US
Mailing Address - Phone:707-544-2811
Mailing Address - Fax:707-544-8671
Practice Address - Street 1:1100 SONOMA AVE
Practice Address - Street 2:SUITE C-1
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-8901
Practice Address - Country:US
Practice Address - Phone:707-544-2811
Practice Address - Fax:707-544-8671
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA228071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice