MEDICARE: DR. RUSSELL W FIFE DDS

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	1223G0001X	General Practice Dentistry	14181	TX

General Provider Information

NPI Number	:	1518962562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL W FIFE DDS

Provider Business Mailing Address
First Line	:	8100 LOMO ALTO DR
Second Line	:	STE 160
City	:	DALLAS
State	:	TX
Zip	:	75225-6530
Country	:	US
Telephone Number	:	214-368-0018
Fax Number	:	469-916-5044

Provider Business Practice Location Address
First Line	:	8100 LOMO ALTO DR
Second Line	:	STE 160
City	:	DALLAS
State	:	TX
Zip	:	75225-6530
Country	:	US
Telephone Number	:	214-368-0018
Fax Number	:	469-916-5044

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	02/02/2011

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