Provider Demographics
NPI:1063592814
Name:HARRIS, PETER A (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
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 1:12251 JAMES ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9675
Mailing Address - Country:US
Mailing Address - Phone:616-393-5694
Mailing Address - Fax:616-393-5643
Practice Address - Street 1:12251 JAMES ST
Practice Address - Street 2:SUITE 400
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9675
Practice Address - Country:US
Practice Address - Phone:616-393-5694
Practice Address - Fax:616-393-5643
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010140301223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI744805457Medicaid