Healthcare Provider Details

I. General information

NPI: 1952584237
Provider Name (Legal Business Name): RONALD D FARRIS DDM, LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21511 SE STARK ST
GRESHAM OR
97030-2025
US

IV. Provider business mailing address

21511 SE STARK ST
GRESHAM OR
97030-2025
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-1698
  • Fax: 503-666-7734
Mailing address:
  • Phone: 503-666-1698
  • Fax: 503-666-7734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-605320
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: