Provider Demographics
NPI:1477880557
Name:HARRIS, MATTHEW L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
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 1:4902 S 1900 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-2993
Mailing Address - Country:US
Mailing Address - Phone:801-773-1237
Mailing Address - Fax:
Practice Address - Street 1:4902 S 1900 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-2993
Practice Address - Country:US
Practice Address - Phone:801-773-1237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist