=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821975590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIFE DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2025
-----------------------------------------------------
Last Update Date | 08/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 776 SAINT ANDREWS BLVD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-7348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-326-4227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 776 SAINT ANDREWS BLVD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-7348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-326-4227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | BRIAN FIFE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-512-3979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------