Provider Demographics
NPI:1649839291
Name:HARRIS, ANDREW
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 I-55 FRONTAGE RD. N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206
Mailing Address - Country:US
Mailing Address - Phone:601-910-0878
Mailing Address - Fax:
Practice Address - Street 1:4505 I-55 FRONTAGE RD. N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206
Practice Address - Country:US
Practice Address - Phone:601-910-0878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4055-191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice