Provider Demographics
NPI:1972612489
Name:ERROL C FIFE DDS PA
Entity Type:Organization
Organization Name:ERROL C FIFE DDS PA
Other - Org Name:HARRISON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERROL
Authorized Official - Middle Name:C
Authorized Official - Last Name:FIFE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-342-3695
Mailing Address - Street 1:1675 W HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0982
Mailing Address - Country:US
Mailing Address - Phone:208-342-3695
Mailing Address - Fax:208-342-4065
Practice Address - Street 1:1675 W HILL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0982
Practice Address - Country:US
Practice Address - Phone:208-342-3695
Practice Address - Fax:208-342-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD 15871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002562000Medicaid