Provider Demographics
NPI:1588852826
Name:FAIRBANKS, BRANDON W (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:W
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3300 N RUNNING CREEK WAY
Mailing Address - Street 2:BLDG F, SUITE 102
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84003
Mailing Address - Country:US
Mailing Address - Phone:801-766-4660
Mailing Address - Fax:801-766-4661
Practice Address - Street 1:3300 N RUNNING CREEK WAY
Practice Address - Street 2:BLDG F, SUITE 102
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84003
Practice Address - Country:US
Practice Address - Phone:801-766-4660
Practice Address - Fax:801-766-4661
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5334209-99211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics