Healthcare Provider Details

I. General information

NPI: 1427706035
Provider Name (Legal Business Name): JACK AUSTIN HARRIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2022
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 N IL ROUTE 31
CRYSTAL LAKE IL
60012-3790
US

IV. Provider business mailing address

690 N IL ROUTE 31
CRYSTAL LAKE IL
60012-3790
US

V. Phone/Fax

Practice location:
  • Phone: 815-459-5600
  • Fax: 815-459-5601
Mailing address:
  • Phone: 815-459-5600
  • Fax: 815-459-5601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.036828
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: