MEDICARE: MARK LEROY HARRIS D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6922	OR

General Provider Information

NPI Number	:	1184622797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LEROY HARRIS D.M.D.

Provider Business Mailing Address
First Line	:	1805 HIGHLAND DR
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-3209
Country	:	US
Telephone Number	:	541-962-0493
Fax Number	:	541-962-0924

Provider Business Practice Location Address
First Line	:	1809 3RD ST
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-2244
Country	:	US
Telephone Number	:	541-963-0924
Fax Number	:	541-962-0924

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/08/2007

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