Provider Demographics
NPI:1679799258
Name:HARRIS, MICHAEL DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:DAVID
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:19800 SW TV TOWER RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:OR
Mailing Address - Zip Code:97378-9649
Mailing Address - Country:US
Mailing Address - Phone:503-580-1798
Mailing Address - Fax:
Practice Address - Street 1:INTERDENT
Practice Address - Street 2:2825 WEST DEVILS LAKE RD
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367
Practice Address - Country:US
Practice Address - Phone:541-994-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist