Provider Demographics
NPI:1205957594
Name:HARPER, MARY ALLISON (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALLISON
Last Name:HARPER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S. 8TH AVE., STOP 8088
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8088
Mailing Address - Country:US
Mailing Address - Phone:208-282-6000
Mailing Address - Fax:208-282-4950
Practice Address - Street 1:465 MEMORIAL DR.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8088
Practice Address - Country:US
Practice Address - Phone:208-282-6000
Practice Address - Fax:208-282-4950
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-39851223G0001X
FLDN175481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice