MEDICARE: MARK HARRIS, D.M.D., P.C.

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	6922	OR

General Provider Information

NPI Number	:	1396043600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK HARRIS, D.M.D., P.C.

Provider Business Mailing Address
First Line	:	1809 3RD ST
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-2244
Country	:	US
Telephone Number	:	541-963-0924
Fax Number	:	541-962-0924

Provider Business Practice Location Address
First Line	:	1809 3RD ST
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-2244
Country	:	US
Telephone Number	:	541-963-0924
Fax Number	:	541-962-0924

Authorized Official
Title or Position	:	DENTIST
Name	:	MARK HARRIS
Credential	:	D.M.D.
Telephone Number	:	541-963-0924

Provider Enumeration Date	:	03/10/2011
Last Update Date	:	03/10/2011

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