Provider Demographics
NPI:1093947665
Name:ERVIN, REX HOMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:REX
Middle Name:HOMER
Last Name:ERVIN
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 1:2650 WASHBURN WAY UNIT 210
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4593
Mailing Address - Country:US
Mailing Address - Phone:541-882-4461
Mailing Address - Fax:541-882-7187
Practice Address - Street 1:2650 WASHBURN WAY
Practice Address - Street 2:UNIT 210
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4596
Practice Address - Country:US
Practice Address - Phone:541-882-4461
Practice Address - Fax:541-882-7187
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR45161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics