Provider Demographics
NPI:1184622797
Name:HARRIS, MARK LEROY (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LEROY
Last Name:HARRIS
Suffix:
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 1:1805 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3209
Mailing Address - Country:US
Mailing Address - Phone:541-962-0493
Mailing Address - Fax:541-962-0924
Practice Address - Street 1:1809 3RD ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2244
Practice Address - Country:US
Practice Address - Phone:541-963-0924
Practice Address - Fax:541-962-0924
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist