Healthcare Provider Details

I. General information

NPI: 1174772784
Provider Name (Legal Business Name): DAVID WAYNE FARNSWORTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E 21ST ST STE B
CLOVIS NM
88101-4492
US

IV. Provider business mailing address

901 E 21ST ST STE B
CLOVIS NM
88101-4492
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-4794
  • Fax:
Mailing address:
  • Phone: 575-762-4794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7520
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3765
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: