Healthcare Provider Details

I. General information

NPI: 1235284662
Provider Name (Legal Business Name): CAMERON GARY FIFE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 CREEKSIDE DR SUITE 103
FOLSOM CA
95630-3830
US

IV. Provider business mailing address

1635 CREEKSIDE DR SUITE 103
FOLSOM CA
95630-3830
US

V. Phone/Fax

Practice location:
  • Phone: 916-983-3436
  • Fax: 916-983-5079
Mailing address:
  • Phone: 916-983-3436
  • Fax: 916-983-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number47617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: