Provider Demographics
NPI:1184923963
Name:HARCOURT, MALLORY CONLEY (RDH)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:CONLEY
Last Name:HARCOURT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25200 CARLOS BEE BLVD APT 562
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94542-1511
Mailing Address - Country:US
Mailing Address - Phone:609-226-6836
Mailing Address - Fax:
Practice Address - Street 1:25200 CARLOS BEE BLVD APT 562
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94542-1511
Practice Address - Country:US
Practice Address - Phone:609-226-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-20
Last Update Date:2011-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25635124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist