Provider Demographics
NPI:1518156991
Name:FAIRBANKS, JON CHRISTIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:CHRISTIAN
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 1:5532 W. HERRIMAN MAIN STREET
Mailing Address - Street 2:#210
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096
Mailing Address - Country:US
Mailing Address - Phone:801-446-9533
Mailing Address - Fax:
Practice Address - Street 1:5532 W. HERRIMAN MAIN STREET
Practice Address - Street 2:#210
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096
Practice Address - Country:US
Practice Address - Phone:801-446-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT66626671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice