Provider Demographics
NPI:1750526117
Name:HARRIS, FAY L (DENTAL HYGIENIST)
Entity type:Individual
Prefix:MS
First Name:FAY
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1271
Mailing Address - Street 2:142 MAPLE STREET
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-3467
Mailing Address - Country:US
Mailing Address - Phone:575-756-1957
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:608 LA JOYA ST STE B
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3467
Practice Address - Country:US
Practice Address - Phone:505-753-9454
Practice Address - Fax:505-753-5815
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH465124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM$$$$$$$$$Medicare Oscar/Certification