Provider Demographics
NPI:1396813416
Name:HARRIS, DANIEL WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:WADE
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:PO BOX 487
Mailing Address - Street 2:206 THIRD STREET
Mailing Address - City:AYDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28513-0487
Mailing Address - Country:US
Mailing Address - Phone:252-746-2161
Mailing Address - Fax:252-746-7412
Practice Address - Street 1:206 3RD ST
Practice Address - Street 2:
Practice Address - City:AYDEN
Practice Address - State:NC
Practice Address - Zip Code:28513-2234
Practice Address - Country:US
Practice Address - Phone:252-746-2161
Practice Address - Fax:252-746-7412
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8993634Medicaid