Healthcare Provider Details

I. General information

NPI: 1215039987
Provider Name (Legal Business Name): PERDITA JAY FISHER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11634 W FLORISSANT AVE
FLORISSANT MO
63033-6723
US

IV. Provider business mailing address

11634 W FLORISSANT AVE
FLORISSANT MO
63033-6723
US

V. Phone/Fax

Practice location:
  • Phone: 314-837-9777
  • Fax: 314-837-9778
Mailing address:
  • Phone: 314-837-9777
  • Fax: 314-837-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13373
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: