MEDICARE: HARRIS DENTAL

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	1641	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	852027	OTHER	ID	INSURANCE

General Provider Information

NPI Number	:	1760686679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRIS DENTAL

Provider Business Mailing Address
First Line	:	3815 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404
Country	:	US
Telephone Number	:	208-529-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3815 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404
Country	:	US
Telephone Number	:	208-529-4500
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JAY M HARRIS
Credential	:	DDS
Telephone Number	:	208-529-4500

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	08/22/2020

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Directions to “HARRIS DENTAL ” Practice Location

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