Healthcare Provider Details

I. General information

NPI: 1871757187
Provider Name (Legal Business Name): GEORGE RAWLEIGH FISHER D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 WOLF CIR
LAKE CHARLES LA
70605
US

IV. Provider business mailing address

1624 WOLF CIR
LAKE CHARLES LA
70605-2348
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-0468
  • Fax: 337-478-3816
Mailing address:
  • Phone: 337-478-0468
  • Fax: 337-478-3816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5401
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: