Provider Demographics
NPI:1760258867
Name:WALLIS, FARRAH R (RDH)
Entity Type:Individual
Prefix:
First Name:FARRAH
Middle Name:R
Last Name:WALLIS
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 1:10229 ADIKSON DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0715
Mailing Address - Country:US
Mailing Address - Phone:501-860-3115
Mailing Address - Fax:
Practice Address - Street 1:1339 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-4235
Practice Address - Country:US
Practice Address - Phone:303-602-0190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002026884124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist