Provider Demographics
NPI:1609550169
Name:FARR, ETHAN G (DDS)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:G
Last Name:FARR
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 1:2444 SAND DOLLAR CT
Mailing Address - Street 2:
Mailing Address - City:SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7986
Mailing Address - Country:US
Mailing Address - Phone:920-660-5799
Mailing Address - Fax:
Practice Address - Street 1:1163 GRAND AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2458
Practice Address - Country:US
Practice Address - Phone:262-673-7826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60011841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice