MEDICARE: DR. JULIAN HARRISON FAIR III DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2173	SC

General Provider Information

NPI Number	:	1689750572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JULIAN HARRISON FAIR III DMD

Provider Business Mailing Address
First Line	:	JULIAN H. FAIR 111,DMD,P.A. , 112 LOUIE STREET
Second Line	:	PO BOX 800
City	:	WAGENER
State	:	SC
Zip	:	29164
Country	:	US
Telephone Number	:	803-564-3446
Fax Number	:	803-564-5254

Provider Business Practice Location Address
First Line	:	JULIAN H. FAIR 111,DMD,P.A. , 112 LOUIE STREET
Second Line	:	112 LOUIE STREET
City	:	WAGENER
State	:	SC
Zip	:	29164
Country	:	US
Telephone Number	:	803-564-3446
Fax Number	:	803-564-5254

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/08/2007

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