Provider Demographics
NPI:1710658653
Name:FAIRBANKS ORTHODONTICS, P.C.
Entity Type:Organization
Organization Name:FAIRBANKS ORTHODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:3300 NORTH RUNNING CREEK WAY
Mailing Address - Street 2:BUILDING F # 102
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043
Mailing Address - Country:US
Mailing Address - Phone:385-336-6604
Mailing Address - Fax:
Practice Address - Street 1:3300 NORTH RUNNING CREEK WAY
Practice Address - Street 2:BUILDING F # 102
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043
Practice Address - Country:US
Practice Address - Phone:385-336-6604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty