Provider Demographics
NPI:1144546102
Name:JONATHAN M. FAIRBANKS, D.D.S., PLLC
Entity type:Organization
Organization Name:JONATHAN M. FAIRBANKS, D.D.S., PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-332-7463
Mailing Address - Street 1:1410 SE BISHOP BLVD # 1S
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5419
Mailing Address - Country:US
Mailing Address - Phone:509-334-6700
Mailing Address - Fax:509-334-9239
Practice Address - Street 1:1410 SE BISHOP BLVD # 1S
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5419
Practice Address - Country:US
Practice Address - Phone:509-334-6700
Practice Address - Fax:509-334-9239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000085871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5033295Medicaid