Provider Demographics
NPI:1699903674
Name:HARRIS, WILLIAM JOSEPH (LD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:ID
Mailing Address - Zip Code:83237-5094
Mailing Address - Country:US
Mailing Address - Phone:208-646-2211
Mailing Address - Fax:
Practice Address - Street 1:1 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:ID
Practice Address - Zip Code:83237-5115
Practice Address - Country:US
Practice Address - Phone:208-646-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD-39122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001863100Medicaid