Provider Demographics
NPI:1053516781
Name:HARRIS, DAVID (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 STONECIPHER BLVD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:580-421-6283
Practice Address - Street 1:2510 CHICKASAW BLVD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1341
Practice Address - Country:US
Practice Address - Phone:580-226-8181
Practice Address - Fax:580-226-5471
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1304190Medicaid