Provider Demographics
NPI:1043686975
Name:HARMON, CONRAD IGNATIUS SR
Entity type:Individual
Prefix:
First Name:CONRAD
Middle Name:IGNATIUS
Last Name:HARMON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 W 46TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1321
Mailing Address - Country:US
Mailing Address - Phone:323-974-1311
Mailing Address - Fax:
Practice Address - Street 1:3004 W 46TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1321
Practice Address - Country:US
Practice Address - Phone:323-974-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28984124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist