Provider Demographics
NPI:1811558208
Name:FAIRVIEW HEIGHTS DENTISTRY, PLLC
Entity Type:Organization
Organization Name:FAIRVIEW HEIGHTS DENTISTRY, PLLC
Other - Org Name:FAIRVIEW HEIGHTS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-310-0263
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:6407 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2720
Practice Address - Country:US
Practice Address - Phone:618-310-0263
Practice Address - Fax:618-212-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty