Provider Demographics
NPI:1255451266
Name:HARRIS, ETHAN DANIEL (DMD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:DANIEL
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 1:2301 CAMINO RAMON STE 294
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4440
Mailing Address - Country:US
Mailing Address - Phone:925-557-7022
Mailing Address - Fax:
Practice Address - Street 1:2301 CAMINO RAMON STE 294
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4440
Practice Address - Country:US
Practice Address - Phone:925-557-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21390122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist