Healthcare Provider Details

I. General information

NPI: 1699850594
Provider Name (Legal Business Name): JACK T FIFIELD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 421 S MAIN STREET
MC KEE KY
40447
US

IV. Provider business mailing address

PO BOX 247
MC KEE KY
40447-0247
US

V. Phone/Fax

Practice location:
  • Phone: 606-287-8326
  • Fax: 606-287-8327
Mailing address:
  • Phone: 606-287-8326
  • Fax: 606-287-8327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4659
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: