Healthcare Provider Details

I. General information

NPI: 1811082167
Provider Name (Legal Business Name): BRUCE EDWARD FARRELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9336 DESCHUTES RD
PALO CEDRO CA
96073-9763
US

IV. Provider business mailing address

9348 DESCHUTES RD STE A
PALO CEDRO CA
96073-8730
US

V. Phone/Fax

Practice location:
  • Phone: 530-547-5744
  • Fax: 530-547-5791
Mailing address:
  • Phone: 530-547-5744
  • Fax: 530-547-5791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43003
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: