MEDICARE: HARRIS I MANN DMD LLC

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	1223G0001X	General Practice Dentistry	DS025302L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	447171	OTHER	PA	UCCI

General Provider Information

NPI Number	:	1235297995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRIS I MANN DMD LLC

Provider Business Mailing Address
First Line	:	11621 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-2513
Country	:	US
Telephone Number	:	215-673-8887
Fax Number	:	215-673-9680

Provider Business Practice Location Address
First Line	:	11621 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-2513
Country	:	US
Telephone Number	:	215-673-8887
Fax Number	:	215-673-9680

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HARRIS I MANN
Credential	:	D.M.D.
Telephone Number	:	215-673-8887

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/16/2008

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Directions to “HARRIS I MANN DMD LLC ” Practice Location

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