Provider Demographics
NPI:1821401324
Name:FIFE, BRADLEY JASON (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JASON
Last Name:FIFE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 COBURG RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4853
Mailing Address - Country:US
Mailing Address - Phone:541-687-1442
Mailing Address - Fax:
Practice Address - Street 1:1507 COBURG RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4853
Practice Address - Country:US
Practice Address - Phone:541-687-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist