Provider Demographics
NPI:1356629059
Name:FAIRBANKS, JAMES LEO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LEO
Last Name:FAIRBANKS
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 1:255 W HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-9069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 W HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9076
Practice Address - Country:US
Practice Address - Phone:573-674-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8385285-9922122300000X
KS613511223G0001X
PADS0402671223G0001X
MO2021026049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103036832 0001Medicaid