Provider Demographics
NPI:1356779995
Name:FAIRBANKS FAMILY DENTAL
Entity type:Organization
Organization Name:FAIRBANKS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:385-275-7400
Mailing Address - Street 1:2414 W 7800 S
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4292
Mailing Address - Country:US
Mailing Address - Phone:385-275-7400
Mailing Address - Fax:385-351-6621
Practice Address - Street 1:2414 W 7800 S
Practice Address - Street 2:SUITE B
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4292
Practice Address - Country:US
Practice Address - Phone:385-275-7400
Practice Address - Fax:385-351-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8385285-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty