Provider Demographics
NPI:1255852364
Name:O'FARRELL, MATTHEW JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
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 1:916 DEWAR DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5915
Mailing Address - Country:US
Mailing Address - Phone:307-362-1720
Mailing Address - Fax:307-362-5561
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:307-362-5561
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice