Healthcare Provider Details

I. General information

NPI: 1669404307
Provider Name (Legal Business Name): DAVID NEAL FAIRCLOTH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 GEORGE C WILSON DR
AUGUSTA GA
30909-4502
US

IV. Provider business mailing address

1222 GEORGE C WILSON DR
AUGUSTA GA
30909-4502
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-9500
  • Fax: 706-868-5081
Mailing address:
  • Phone: 706-868-9500
  • Fax: 706-868-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10995
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3369
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: