Healthcare Provider Details

I. General information

NPI: 1699903674
Provider Name (Legal Business Name): WILLIAM JOSEPH HARRIS LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E MAIN ST
FRANKLIN ID
83237-5115
US

IV. Provider business mailing address

22 N STATE ST
FRANKLIN ID
83237-5094
US

V. Phone/Fax

Practice location:
  • Phone: 208-646-2211
  • Fax:
Mailing address:
  • Phone: 208-646-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD-39
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: