Basic Information
| Provider Information | |||||||||
| NPI: | 1326613266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ROCHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 GREAT RIVER RD APT 320 | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021451220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702960186 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 45 DIMOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124428800 | ||||||||
| FaxNumber: | 6174424088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2021 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | DN1859155 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.