Healthcare Provider Details

I. General information

NPI: 1609550169
Provider Name (Legal Business Name): ETHAN G FARR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4082 N RICHMOND ST
APPLETON WI
54913-9704
US

IV. Provider business mailing address

5433 N JASPER LN
APPLETON WI
54913-2776
US

V. Phone/Fax

Practice location:
  • Phone: 920-734-9148
  • Fax:
Mailing address:
  • Phone: 920-660-5799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number6001184
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number6001184
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001184
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: