Provider Demographics
NPI:1619302080
Name:FARRIS, DAVID LYLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LYLE
Last Name:FARRIS
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 1:16548 NORTH FRANKLIN BLVD.
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687
Mailing Address - Country:US
Mailing Address - Phone:208-461-3070
Mailing Address - Fax:208-461-3071
Practice Address - Street 1:16548 NORTH FRANKLIN BLVD.
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-461-3070
Practice Address - Fax:208-461-3071
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66D17751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice