MEDICARE: FAIRVIEW HEIGHTS DENTISTRY, PLLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1811558208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRVIEW HEIGHTS DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:	714-845-8500
Fax Number	:	303-952-0892

Provider Business Practice Location Address
First Line	:	6407 N ILLINOIS ST
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2720
Country	:	US
Telephone Number	:	618-310-0263
Fax Number	:	618-212-9054

Authorized Official
Title or Position	:	OWNER
Name	:	BRYAN K WATANABE
Credential	:
Telephone Number	:	618-310-0263

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	03/08/2022

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