Provider Demographics
NPI:1063497766
Name:FARRELL, CHARLES D (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:D
Last Name:FARRELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5467
Mailing Address - Country:US
Mailing Address - Phone:515-232-6830
Mailing Address - Fax:515-232-3296
Practice Address - Street 1:1212 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5467
Practice Address - Country:US
Practice Address - Phone:515-232-6830
Practice Address - Fax:515-232-3296
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA57641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
14605Medicare UPIN