Provider Demographics
NPI:1720104441
Name:FARLESS, CARL (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:FARLESS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4475 VINELAND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-3429
Mailing Address - Country:US
Mailing Address - Phone:818-509-0107
Mailing Address - Fax:818-509-1109
Practice Address - Street 1:4475 VINELAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-3429
Practice Address - Country:US
Practice Address - Phone:818-509-0107
Practice Address - Fax:818-509-1109
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA316041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice