=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598903122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVAN FARR D.D.S INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2009
-----------------------------------------------------
Last Update Date | 04/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12115 SATICOY ST
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91605-3025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-759-1001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23705 VANOWEN ST # 308
-----------------------------------------------------
City | WEST HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91307-3030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-521-4049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. EAVN FARR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-521-4049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 49261
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------