Provider Demographics
NPI:1174677900
Name:O'FARRELL, MARK G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:O'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 1:1827 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-7343
Mailing Address - Country:US
Mailing Address - Phone:307-362-8688
Mailing Address - Fax:
Practice Address - Street 1:916 DEWAR DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5915
Practice Address - Country:US
Practice Address - Phone:307-362-1720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist