Healthcare Provider Details

I. General information

NPI: 1497045694
Provider Name (Legal Business Name): NATHANIAL EDWARD FARLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2011
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 S VAL VISTA DR STE 103
MESA AZ
85204-5667
US

IV. Provider business mailing address

1056 S VAL VISTA DR STE 103
MESA AZ
85204-5667
US

V. Phone/Fax

Practice location:
  • Phone: 480-832-1375
  • Fax:
Mailing address:
  • Phone: 480-832-1375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberRES.2744
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number6758
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD009976
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: