Provider Demographics
NPI:1376684886
Name:RICHARD J. FAIRBROTHER, DMD, LLC
Entity Type:Organization
Organization Name:RICHARD J. FAIRBROTHER, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAIRBROTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-232-2000
Mailing Address - Street 1:69 SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2410
Mailing Address - Country:US
Mailing Address - Phone:860-232-2000
Mailing Address - Fax:860-233-8842
Practice Address - Street 1:69 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2410
Practice Address - Country:US
Practice Address - Phone:860-232-2000
Practice Address - Fax:860-233-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0057851223G0001X
CT0036831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty