Healthcare Provider Details

I. General information

NPI: 1316460009
Provider Name (Legal Business Name): KAYCI M HARRIS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 STATE HIGHWAY 68
EMBUDO NM
87531
US

IV. Provider business mailing address

PO BOX 37
EMBUDO NM
87531-0037
US

V. Phone/Fax

Practice location:
  • Phone: 505-579-4680
  • Fax: 505-579-4074
Mailing address:
  • Phone: 505-579-4680
  • Fax: 505-579-4074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4761
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: