Healthcare Provider Details

I. General information

NPI: 1841382728
Provider Name (Legal Business Name): EDWIN LEE FARRAR D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 LEXINGTON AVE
MANSFIELD OH
44907-1500
US

IV. Provider business mailing address

630 LEXINGTON AVE
MANSFIELD OH
44907-1500
US

V. Phone/Fax

Practice location:
  • Phone: 419-756-0711
  • Fax: 419-756-4886
Mailing address:
  • Phone: 419-756-0711
  • Fax: 419-756-4886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number17535
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: