Provider Demographics
NPI:1316329758
Name:FAIRBANKS, PAUL (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
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 1:601 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1717
Mailing Address - Country:US
Mailing Address - Phone:541-447-4888
Mailing Address - Fax:
Practice Address - Street 1:601 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-447-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist