MEDICARE: DR. JAY M. HARRIS

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	PROVIDER NUMBER

General Provider Information

NPI Number	:	1851438709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY M. HARRIS

Provider Business Mailing Address
First Line	:	3815 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7591
Country	:	US
Telephone Number	:	208-529-4500
Fax Number	:	208-524-6248

Provider Business Practice Location Address
First Line	:	3815 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7591
Country	:	US
Telephone Number	:	208-529-4500
Fax Number	:	208-524-6248

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

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	07/09/2007

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