Healthcare Provider Details

I. General information

NPI: 1114327152
Provider Name (Legal Business Name): MARLA HARRIS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5033 VINCENT AVE N
MINNEAPOLIS MN
55430-3343
US

IV. Provider business mailing address

5033 VINCENT AVE N
MINNEAPOLIS MN
55430-3343
US

V. Phone/Fax

Practice location:
  • Phone: 612-381-6977
  • Fax:
Mailing address:
  • Phone: 612-381-6977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH8209
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: