Provider Demographics
NPI:1881848141
Name:HARRIS, BRIAN (DDS, MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 HERMITAGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4604
Mailing Address - Country:US
Mailing Address - Phone:215-482-1818
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:5 WHITE BLDG., DEPT OF ORAL AND MAXILLOFACIAL SURGERY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0350631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery