Healthcare Provider Details

I. General information

NPI: 1982908000
Provider Name (Legal Business Name): JACK M. FIEDLER, D.D.S.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 GREENWOOD AVE W BOX 547
HECTOR MN
55342
US

IV. Provider business mailing address

150 GREENWOOD AVE W BOX 547
HECTOR MN
55342
US

V. Phone/Fax

Practice location:
  • Phone: 320-848-2611
  • Fax: 320-848-2611
Mailing address:
  • Phone: 320-848-2611
  • Fax: 320-848-2611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12373
License Number StateMN

VIII. Authorized Official

Name: DR. JACK M. FIEDLER
Title or Position: OWNER
Credential: D.D.S.
Phone: 320-848-2611