Active NPI
James Leo Fairbanks, DMD
- Dentist
- Fort Leonard Wood, MO
National Provider Identifier
1356629059
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 2021026049
- Practice address
- 4430 Missouri Ave
Fort Leonard Wood, MO 65473-9098 - Phone
- (573) 596-0417
- NPI assigned
- Jul 28, 2011
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 4
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 8385285-9922 | UT | |
| General Practice Dentistry | 1223G0001X | 61351 | KS | |
| General Practice Dentistry | 1223G0001X | DS040267 | PA | |
| Dentist | 122300000X | 2021026049 | MO | Primary |
Addresses
Primary practice location
4430 Missouri Ave
Fort Leonard Wood, MO 65473-9098
Mailing address
4430 Missouri Ave
Fort Leonard Wood, MO 65473-9098
Phone (573) 596-0417
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 103036832 0001 | Medicaid | PA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2021026049 | MO | MD | Dentist |
| 8385285-9922 | UT | MD | Dentist |
| 61351 | KS | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1311811200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1730073600000",
"number": "1356629059",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4430 MISSOURI AVE",
"city": "FORT LEONARD WOOD",
"state": "MO",
"postal_code": "654739098",
"telephone_number": "573-596-0417"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4430 MISSOURI AVE",
"city": "FORT LEONARD WOOD",
"state": "MO",
"postal_code": "654739098",
"telephone_number": "573-596-0417"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FAIRBANKS",
"first_name": "JAMES",
"middle_name": "LEO",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-07-28",
"last_updated": "2024-10-28",
"certification_date": "2024-10-28",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "UT",
"license": "8385285-9922",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "KS",
"license": "61351",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "PA",
"license": "DS040267",
"primary": false
},
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MO",
"license": "2021026049",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "103036832 0001",
"state": "PA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Leonard Wood, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.