Provider Demographics
NPI:1851438709
Name:HARRIS, JAY M
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7591
Mailing Address - Country:US
Mailing Address - Phone:208-529-4500
Mailing Address - Fax:208-524-6248
Practice Address - Street 1:3815 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7591
Practice Address - Country:US
Practice Address - Phone:208-529-4500
Practice Address - Fax:208-524-6248
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID16411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID852027OtherPROVIDER NUMBER