MEDICARE: DR. MARK E HARRIS DDS

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	D3622	ID
2	1223G0001X	General Practice Dentistry	6822295	UT

General Provider Information

NPI Number	:	1669419701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK E HARRIS DDS

Provider Business Mailing Address
First Line	:	2274 N 400 E
Second Line	:	SUITE 204
City	:	NORTH OGDEN
State	:	UT
Zip	:	84414
Country	:	US
Telephone Number	:	801-399-0458
Fax Number	:	801-393-2212

Provider Business Practice Location Address
First Line	:	2274 N 400 E
Second Line	:	SUITE 204
City	:	NORTH OGDEN
State	:	UT
Zip	:	84414
Country	:	US
Telephone Number	:	801-399-0458
Fax Number	:	801-393-2212

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	04/16/2009

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