Provider Demographics
NPI:1578054367
Name:WILLIS-FARMER, KATHLEEN (RDH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WILLIS-FARMER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10590 ENDURING FREEDOM DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10590 ENDURING FREEDOM DRIVE
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X
CA19916124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19916OtherMILITARY BASE