Healthcare Provider Details

I. General information

NPI: 1972174175
Provider Name (Legal Business Name): RAYMOND FAHRENBACH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL JACKSONVILLE 2080 CHILD STREET
JACKSONVILLE FL
32214-6122
US

IV. Provider business mailing address

1 PINCKNEY BLVD
BEAUFORT SC
29902-6122
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7460
  • Fax:
Mailing address:
  • Phone: 843-228-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9964
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: