MEDICARE: DR. JESSE WILSON HARKER D. D. S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D7857	AZ

General Provider Information

NPI Number	:	1053543819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE WILSON HARKER D. D. S.

Provider Business Mailing Address
First Line	:	371 LAKE HAVASU AVE S
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9307
Country	:	US
Telephone Number	:	928-855-8333
Fax Number	:	928-855-8333

Provider Business Practice Location Address
First Line	:	371 LAKE HAVASU AVE S
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9307
Country	:	US
Telephone Number	:	928-855-8333
Fax Number	:	928-855-8333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2009
Last Update Date	:	08/12/2009

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