Provider Demographics
NPI:1245236223
Name:HARRIS, JOHN CROOM (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CROOM
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 BRYANT IRVIN RD STE 107
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4212
Mailing Address - Country:US
Mailing Address - Phone:817-732-4041
Mailing Address - Fax:
Practice Address - Street 1:4200 BRYANT IRVIN RD
Practice Address - Street 2:STE 107
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-4212
Practice Address - Country:US
Practice Address - Phone:817-732-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14190332B00000X
TXAH141901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies