Provider Demographics
NPI:1720891880
Name:FAIRLEY, MIA R (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:R
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 KUBOTA LN
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9561
Mailing Address - Country:US
Mailing Address - Phone:509-727-3535
Mailing Address - Fax:
Practice Address - Street 1:4406 KUBOTA LN
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9561
Practice Address - Country:US
Practice Address - Phone:509-727-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00007998124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist