=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225052392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK FLOYD HARRIS D.D.S.,P.A
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 10/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 N GREEN ACRES RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-521-6365
-----------------------------------------------------
Fax | 479-521-6364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 N GREEN ACRES RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-521-6365
-----------------------------------------------------
Fax | 479-521-6364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3504
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------