Provider Demographics
NPI:1598851479
Name:FARRELL, JEROME THOMAS II (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:THOMAS
Last Name:FARRELL
Suffix:II
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2089
Mailing Address - Country:US
Mailing Address - Phone:607-729-4539
Mailing Address - Fax:607-797-7926
Practice Address - Street 1:301 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2089
Practice Address - Country:US
Practice Address - Phone:607-729-4539
Practice Address - Fax:607-797-7926
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY368561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00852855Medicaid