Provider Demographics
NPI:1386279834
Name:HARRIS, LISA ILENE (DMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ILENE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 ARNOLD WAY
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1207
Mailing Address - Country:US
Mailing Address - Phone:860-707-3216
Mailing Address - Fax:
Practice Address - Street 1:264 QUEEN ST UNIT A
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1901
Practice Address - Country:US
Practice Address - Phone:860-426-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12875390200000X
CT133371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program