Provider Demographics
NPI:1780203174
Name:HARRIS, MARK LEE II (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:HARRIS
Suffix:II
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 1:340 MAGNOLIA CIR # 5612
Mailing Address - Street 2:
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403-5612
Mailing Address - Country:US
Mailing Address - Phone:850-283-2778
Mailing Address - Fax:
Practice Address - Street 1:340 MAGNOLIA CIR
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:502-837-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSTUDENT122300000X
VA0401417042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty