Provider Demographics
NPI:1609427947
Name:FIFE, JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FIFE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 HUBBARD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3021
Mailing Address - Country:US
Mailing Address - Phone:018-887-9058
Mailing Address - Fax:775-888-4904
Practice Address - Street 1:660 E EAU GALLIE BLVD
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4256
Practice Address - Country:US
Practice Address - Phone:321-777-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN287171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN28717OtherFLORIDA STATE DENTAL LICENSE