Provider Demographics
NPI:1952584237
Name:FARRIS, RONALD D (DDM, LD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:FARRIS
Suffix:
Gender:M
Credentials:DDM, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21511 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2025
Mailing Address - Country:US
Mailing Address - Phone:503-666-1698
Mailing Address - Fax:503-666-7734
Practice Address - Street 1:21511 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2025
Practice Address - Country:US
Practice Address - Phone:503-666-1698
Practice Address - Fax:503-666-7734
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-605320122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist