Provider Demographics
NPI:1578676698
Name:HARRIS, ROGER MARVIN III (DMD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:MARVIN
Last Name:HARRIS
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 S. BATESVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-4524
Mailing Address - Country:US
Mailing Address - Phone:864-877-9111
Mailing Address - Fax:864-877-9195
Practice Address - Street 1:920 S. BATESVILLE ROAD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4524
Practice Address - Country:US
Practice Address - Phone:864-877-9111
Practice Address - Fax:864-877-9195
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3557Medicaid
449325OtherUNITED CONCORDIA