MEDICARE: DR. DAVID NEAL FAIRCLOTH 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	10995	GA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	3369	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GRP5093	OTHER	GA	MEDICARE GA GROUP
3	7561	OTHER	SC	MEDICARE SC GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669404307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID NEAL FAIRCLOTH DMD

Provider Business Mailing Address
First Line	:	1222 GEORGE C WILSON DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-4502
Country	:	US
Telephone Number	:	706-868-9500
Fax Number	:	706-868-5081

Provider Business Practice Location Address
First Line	:	1222 GEORGE C WILSON DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-4502
Country	:	US
Telephone Number	:	706-868-9500
Fax Number	:	706-868-5081

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	01/21/2008

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Directions to “ DR. DAVID NEAL FAIRCLOTH DMD” Practice Location

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