Provider Demographics
NPI:1376750836
Name:HARRIS, SHANALYN MARAE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANALYN
Middle Name:MARAE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-3038
Mailing Address - Country:US
Mailing Address - Phone:601-736-3286
Mailing Address - Fax:601-736-3939
Practice Address - Street 1:433 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3038
Practice Address - Country:US
Practice Address - Phone:601-736-3286
Practice Address - Fax:601-736-3939
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3113-991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice