Healthcare Provider Details

I. General information

NPI: 1568547321
Provider Name (Legal Business Name): RANDALL D HARRIS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 ROUTE 12
GALES FERRY CT
06335-0396
US

IV. Provider business mailing address

PO BOX 396
GALES FERRY CT
06335-0396
US

V. Phone/Fax

Practice location:
  • Phone: 860-464-7204
  • Fax: 860-464-0186
Mailing address:
  • Phone: 860-464-7204
  • Fax: 860-464-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL D HARRIS
Title or Position: DENTIST PRESIDENT
Credential: DDS
Phone: 860-464-7204