Provider Demographics
NPI:1316166218
Name:FAIRBANKS, JONATHAN M (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:FAIRBANKS
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 1:910 SE HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-2230
Mailing Address - Country:US
Mailing Address - Phone:509-332-7463
Mailing Address - Fax:509-332-5456
Practice Address - Street 1:1410 SE BISHOP BLVD
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:509-332-2329
Practice Address - Fax:506-334-9239
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8587122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist