Provider Demographics
NPI:1053904268
Name:HARRIS, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:619-524-4487
Mailing Address - Fax:
Practice Address - Street 1:32389 ECHO LN
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92147-5196
Practice Address - Country:US
Practice Address - Phone:619-524-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist