Provider Demographics
NPI:1790911170
Name:FARREY, KAJUANA PEARLDEALIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:KAJUANA
Middle Name:PEARLDEALIA
Last Name:FARREY
Suffix:
Gender:F
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:PO BOX 2229
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2229
Mailing Address - Country:US
Mailing Address - Phone:229-890-3908
Mailing Address - Fax:229-890-3909
Practice Address - Street 1:513 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-4637
Practice Address - Country:US
Practice Address - Phone:229-890-3908
Practice Address - Fax:229-890-3909
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-30
Last Update Date:2011-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0138801223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA148974731BMedicaid