Provider Demographics
NPI:1023717600
Name:FAIRBANKS, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3018 N ARGONNE RD
Mailing Address - Street 2:
Mailing Address - City:MILLWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:99212-2179
Mailing Address - Country:US
Mailing Address - Phone:509-993-6198
Mailing Address - Fax:
Practice Address - Street 1:3018 N ARGONNE RD
Practice Address - Street 2:
Practice Address - City:MILLWOOD
Practice Address - State:WA
Practice Address - Zip Code:99212-2179
Practice Address - Country:US
Practice Address - Phone:509-928-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
WADENT.DE.700131061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program