Healthcare Provider Details

I. General information

NPI: 1588194088
Provider Name (Legal Business Name): JOHN W FLEISCHMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/14/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ABERDEEN PROVING GROUND DENTAL CLINIC 2501 MACHINE ST
ABERDEEN PROVING GROUND MD
21005
US

IV. Provider business mailing address

SMOKE BOMB HILL DC GRUBER
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 410-278-1795
  • Fax:
Mailing address:
  • Phone: 910-643-2578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00203167
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00203167
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: