Provider Demographics
NPI:1679595003
Name:FAIRCLOTH, W. JACKSON JR (DDS)
Entity type:Individual
Prefix:DR
First Name:W. JACKSON
Middle Name:
Last Name:FAIRCLOTH
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 HYDRAULIC RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-8124
Mailing Address - Country:US
Mailing Address - Phone:434-973-3348
Mailing Address - Fax:434-977-5790
Practice Address - Street 1:244 HYDRAULIC RIDGE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-8124
Practice Address - Country:US
Practice Address - Phone:434-973-3348
Practice Address - Fax:434-977-5790
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH56551Medicare UPIN