Provider Demographics
NPI:1891127221
Name:FARWELL DENTAL CLINIC
Entity Type:Organization
Organization Name:FARWELL DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:ROE
Authorized Official - Last Name:IVINS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-481-3336
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:TX
Mailing Address - Zip Code:79325-0800
Mailing Address - Country:US
Mailing Address - Phone:806-481-3336
Mailing Address - Fax:806-481-3339
Practice Address - Street 1:303 3RD ST
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:TX
Practice Address - Zip Code:79325-4669
Practice Address - Country:US
Practice Address - Phone:806-481-3336
Practice Address - Fax:806-481-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11608261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0087520-1Medicaid