Healthcare Provider Details

I. General information

NPI: 1407896780
Provider Name (Legal Business Name): MICHAEL C FAIR JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3360 TREMONT RD STE 100
COLUMBUS OH
43221-2111
US

IV. Provider business mailing address

3360 TREMONT RD STE 100
COLUMBUS OH
43221-2111
US

V. Phone/Fax

Practice location:
  • Phone: 614-451-7377
  • Fax:
Mailing address:
  • Phone: 614-451-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.022165
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30022165
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: