Provider Demographics
NPI:1104605989
Name:ETHAN LAFFERTY, DDS, PLLC
Entity type:Organization
Organization Name:ETHAN LAFFERTY, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:SHAMUS
Authorized Official - Last Name:LAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-327-7135
Mailing Address - Street 1:1321 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-3318
Mailing Address - Country:US
Mailing Address - Phone:304-327-7135
Mailing Address - Fax:304-327-0758
Practice Address - Street 1:1321 STADIUM DR
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3318
Practice Address - Country:US
Practice Address - Phone:304-327-7135
Practice Address - Fax:304-327-0758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty