NPIMap

Organization Active NPI

Fairview Heights Dentistry, PLLC

Doing business as Fairview Heights Dentistry

  • Dentist
  • Fairview Heights, IL
National Provider Identifier
1811558208
Registry record updated Mar 8, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
FAIRVIEW HEIGHTS DENTISTRY, PLLC
Doing business as
Fairview Heights Dentistry
Practice address
6407 N Illinois St
Fairview Heights, IL 62208-2720
Phone
(618) 310-0263
Fax
(618) 212-9054
NPI assigned
Jun 26, 2019
Last updated
Mar 8, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 8, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bryan K Watanabe
Title
Owner
Phone
(618) 310-0263

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X Primary

Addresses

Primary practice location

6407 N Illinois St
Fairview Heights, IL 62208-2720

Mailing address

PO Box 920050
Dallas, TX 75392-0050
Phone (714) 845-8500

Other names 1

  • Fairview Heights Dentistry Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1561507200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646697600000",
    "number": "1811558208",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 920050",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "753920050",
            "telephone_number": "714-845-8500",
            "fax_number": "303-952-0892"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6407 N ILLINOIS ST",
            "city": "FAIRVIEW HEIGHTS",
            "state": "IL",
            "postal_code": "622082720",
            "telephone_number": "618-310-0263",
            "fax_number": "618-212-9054"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRVIEW HEIGHTS DENTISTRY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-26",
        "last_updated": "2022-03-08",
        "certification_date": "2022-03-08",
        "status": "A",
        "authorized_official_last_name": "WATANABE",
        "authorized_official_first_name": "BRYAN",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "618-310-0263"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fairview Heights Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fairview Heights, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.