Provider Demographics
NPI:1083640007
Name:HARRELL, MARY KATHLEEN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:HARRELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:KIMBALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2222 SW QUINNEY DR.
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801
Mailing Address - Country:US
Mailing Address - Phone:541-240-4497
Mailing Address - Fax:541-504-3907
Practice Address - Street 1:1519 NE F ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-4234
Practice Address - Country:US
Practice Address - Phone:542-240-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7115122300000X, 1223G0001X
ID91610761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist