Healthcare Provider Details

I. General information

NPI: 1023462330
Provider Name (Legal Business Name): MARK E HARRIS D D S INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5925 BROCKTON AVE STE B
RIVERSIDE CA
92506-7800
US

IV. Provider business mailing address

5925 BROCKTON AVE STE B
RIVERSIDE CA
92506-7800
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-4988
  • Fax: 951-684-4899
Mailing address:
  • Phone: 951-684-4988
  • Fax: 951-684-4899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number51258
License Number StateCA

VIII. Authorized Official

Name: DR. MARK E HARRIS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 951-684-4988