MEDICARE: DR. MARY THERESA HARRIS DDS

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	019031314	IL

General Provider Information

NPI Number	:	1417471327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY THERESA HARRIS DDS

Provider Business Mailing Address
First Line	:	101 S HALE ST
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-6211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 CARLEMONT DR
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-1833
Country	:	US
Telephone Number	:	815-477-2273
Fax Number	:

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

Provider Enumeration Date	:	08/01/2017
Last Update Date	:	12/28/2020

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