Provider Demographics
NPI:1699239731
Name:HARRIS, LAURAL LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:LAURAL
Middle Name:LEE
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 1:1304 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2806
Mailing Address - Country:US
Mailing Address - Phone:563-676-3735
Mailing Address - Fax:
Practice Address - Street 1:124 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1053
Practice Address - Country:US
Practice Address - Phone:563-676-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0244721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice