Provider Demographics
NPI:1568992733
Name:FAIRBANKS, KYLE JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JOSEPH
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 1:710 W MELROSE ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3418
Mailing Address - Country:US
Mailing Address - Phone:847-370-9280
Mailing Address - Fax:
Practice Address - Street 1:2500 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5202
Practice Address - Country:US
Practice Address - Phone:773-360-1281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist