Provider Demographics
NPI:1639234370
Name:FAIRLESS, HEATHER LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LEE
Last Name:FAIRLESS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39087 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-2789
Mailing Address - Country:US
Mailing Address - Phone:586-286-7200
Mailing Address - Fax:
Practice Address - Street 1:39087 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-2789
Practice Address - Country:US
Practice Address - Phone:586-286-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003707152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist