Healthcare Provider Details

I. General information

NPI: 1801887385
Provider Name (Legal Business Name): MICHAEL E HARRIS DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W JOHN FITCH AVE
BARDSTOWN KY
40004-1115
US

IV. Provider business mailing address

218 W JOHN FITCH AVE
BARDSTOWN KY
40004-1115
US

V. Phone/Fax

Practice location:
  • Phone: 502-348-9775
  • Fax: 502-348-2756
Mailing address:
  • Phone: 502-348-9775
  • Fax: 502-348-2756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4122
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: