Individual
DR. CONNOR FAIRBANKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
921 S 8TH AVE STOP 8088, POCATELLO, ID 83209-0002
(208) 282-6000
Mailing address
921 S 8TH AVE STOP 8088, POCATELLO, ID 83209-8088
(208) 282-6000
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D-4836
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
D-4836
IDAHO STATE BOARD OF DENTISTRY (DENTAL LICENSE)
ID
Enumeration date
07/03/2017
Last updated
07/03/2017
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