Healthcare Provider Details

I. General information

NPI: 1881777969
Provider Name (Legal Business Name): KENNETH JOHN FISCHER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1467 N WANDA RD STE 195
VILLA PARK CA
92867-5344
US

IV. Provider business mailing address

7821 E PORTICO TER
ORANGE CA
92867-6481
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-1200
  • Fax: 714-633-4740
Mailing address:
  • Phone: 714-904-7264
  • Fax: 714-633-4740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number23603
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: