Healthcare Provider Details

I. General information

NPI: 1609092568
Provider Name (Legal Business Name): OLLIE CHRISTOPHER FISHER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
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

11012 OLD HALLS FERRY RD
SAINT LOUIS MO
63136-4630
US

V. Phone/Fax

Practice location:
  • Phone: 314-837-9777
  • Fax:
Mailing address:
  • Phone: 314-741-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12781
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: