Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D-1587 | ID |
NPI | 1003853904 |
---|---|
Provider Name | Dr. Errol Chandler Fife |
First Address | Boise, ID 83702-0982 |
Second Address | Boise, ID 83702-0982 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0025620000 | (05) | ID |