Provider Demographics
NPI:1265731442
Name:FARREY FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:FARREY FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAJUANA
Authorized Official - Middle Name:PEARLDEALIA
Authorized Official - Last Name:FARREY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-890-3908
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-27
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0138801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA148974731BMedicaid