Provider Demographics
NPI:1972766277
Name:FAIR, MICHAEL CARLTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CARLTON
Last Name:FAIR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13455 N LON ADAMS RD
Mailing Address - Street 2:PO BOX 936
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653
Mailing Address - Country:US
Mailing Address - Phone:520-616-0790
Mailing Address - Fax:520-616-0921
Practice Address - Street 1:13455 N LON ADAMS RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653
Practice Address - Country:US
Practice Address - Phone:520-616-0790
Practice Address - Fax:520-616-0921
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice