Provider Demographics
NPI:1669404307
Name:FAIRCLOTH, DAVID NEAL (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:NEAL
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 GEORGE C WILSON DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4502
Mailing Address - Country:US
Mailing Address - Phone:706-868-9500
Mailing Address - Fax:706-868-5081
Practice Address - Street 1:1222 GEORGE C WILSON DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4502
Practice Address - Country:US
Practice Address - Phone:706-868-9500
Practice Address - Fax:706-868-5081
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109951223S0112X
SC33691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5093OtherMEDICARE GA GROUP
SCZ33697Medicaid
SC7561OtherMEDICARE SC GROUP
GA00707396BMedicaid
SCZ33697Medicaid
GA00707396BMedicaid