Provider Demographics
NPI:1386918654
Name:HARRIS, WILLIAM GORDON (BSC, DDS)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GORDON
Last Name:HARRIS
Suffix:
Gender:M
Credentials:BSC, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 E 2 AVE S,
Mailing Address - Street 2:BOX 654
Mailing Address - City:MAGRATH
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T0K 1J0
Mailing Address - Country:CA
Mailing Address - Phone:403-758-6006
Mailing Address - Fax:403-320-1137
Practice Address - Street 1:6965 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6256
Practice Address - Country:US
Practice Address - Phone:916-791-7998
Practice Address - Fax:916-791-5551
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist