Provider Demographics
NPI:1508966300
Name:FAIRFAX, RONALD EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:EDWARD
Last Name:FAIRFAX
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:PO BOX 3150
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-3150
Mailing Address - Country:US
Mailing Address - Phone:208-788-0048
Mailing Address - Fax:208-788-8575
Practice Address - Street 1:14 E. ELM ST.
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333
Practice Address - Country:US
Practice Address - Phone:208-788-0048
Practice Address - Fax:208-788-8575
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD32211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice