Provider Demographics
NPI:1558300798
Name:FAIRBANKS, MARCUS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:A
Last Name:FAIRBANKS
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 1:3628 MERIDIAN ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1735
Mailing Address - Country:US
Mailing Address - Phone:360-676-9050
Mailing Address - Fax:360-676-1593
Practice Address - Street 1:3628 MERIDIAN ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1735
Practice Address - Country:US
Practice Address - Phone:360-676-9050
Practice Address - Fax:360-676-1593
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA51141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5555008Medicaid
WADE00005114OtherHEALTH PROF QUALITTY ASSU
WAAF8381345OtherDEA NUMBER