Healthcare Provider Details

I. General information

NPI: 1063680098
Provider Name (Legal Business Name): MARK LYMAN FARMER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22470 COUNTY ROAD 32.5
JULESBURG CO
80737-9662
US

IV. Provider business mailing address

22470 COUNTY ROAD 32.5
JULESBURG CO
80737-9662
US

V. Phone/Fax

Practice location:
  • Phone: 970-474-2763
  • Fax:
Mailing address:
  • Phone: 970-474-2763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN105667
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: