Provider Demographics
NPI:1952896870
Name:HARRIS, JUSTIN LANE (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LANE
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 1:2431 W MAIN ST STE 601
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1270
Mailing Address - Country:US
Mailing Address - Phone:801-529-8055
Mailing Address - Fax:
Practice Address - Street 1:2431 W MAIN ST STE 601
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1270
Practice Address - Country:US
Practice Address - Phone:336-793-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL65261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice