Provider Demographics
NPI:1952963365
Name:HARRIS, LANCE RICHARD
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:RICHARD
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 1:19593 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7564
Mailing Address - Country:US
Mailing Address - Phone:760-213-2739
Mailing Address - Fax:
Practice Address - Street 1:2050 BARB ST
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98315-2050
Practice Address - Country:US
Practice Address - Phone:360-315-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE609687621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice