Basic Information
| Provider Information | |||||||||
| NPI: | 1487687786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARSHA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | MITCHELL | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 CARIBBEAN DR | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815061759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702548759 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2121 NORTH AVE | ||||||||
| Address2: | 160 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815016428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702420731 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 104427 | CO | Y | Dental Providers | Dentist | General Practice |
No ID Information.