Provider Demographics
NPI:1093976904
Name:FAIRHURST, KEVIN JON (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JON
Last Name:FAIRHURST
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-1747
Mailing Address - Country:US
Mailing Address - Phone:406-761-1365
Mailing Address - Fax:406-403-0418
Practice Address - Street 1:900 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-1747
Practice Address - Country:US
Practice Address - Phone:406-761-1365
Practice Address - Fax:406-403-0418
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4144122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT2397OtherMONTANA LICENCE NUMBER