Provider Demographics
NPI:1972174175
Name:FAHRENBACH, RAYMOND (DDS)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:FAHRENBACH
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 1:1 PINCKNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6122
Mailing Address - Country:US
Mailing Address - Phone:843-228-5600
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL JACKSONVILLE 2080 CHILD STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-6122
Practice Address - Country:US
Practice Address - Phone:904-542-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9964122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist