Healthcare Provider Details

I. General information

NPI: 1609427947
Provider Name (Legal Business Name): JOHN FIFE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 E EAU GALLIE BLVD
INDIAN HARBOUR BEACH FL
32937-4256
US

IV. Provider business mailing address

1728 HUBBARD DR
ROCKLEDGE FL
32955-3021
US

V. Phone/Fax

Practice location:
  • Phone: 321-777-7474
  • Fax:
Mailing address:
  • Phone: 18-887-9058
  • Fax: 775-888-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN28717
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: