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General NPI Number Information
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NPI Number | 1497002216
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Entity Type | Organization
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Legal Business Name | THREE LAKES DENTAL, P.C.
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Dates
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Enumeration Date | 08/10/2012
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Last Update Date | 08/10/2012
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Provider Practice Location Address
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Address Line | 1619 GILMER AVE
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City | TALLASSEE
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State | AL
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Zip | 36078-2313
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Country | US
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Telephone | 334-252-9000
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Fax | 334-252-9003
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Provider Business Mailing Address
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Address Line | 1619 GILMER AVE
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City | TALLASSEE
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State | AL
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Zip | 36078-2313
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Country | US
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Telephone | 334-252-9000
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Fax | 334-252-9003
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Authorized Official
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Title or Position | OWNER, DENTIST
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Name | DR. ERIC S HARRIS
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Credential | DMD
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Telephone | 334-252-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5796
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License Number State | AL
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