Healthcare Provider Details

I. General information

NPI: 1568468130
Provider Name (Legal Business Name): MICHAEL J FIDLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: MR. MICHAEL J FIDLER

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

161 RIVERSIDE DR STE 201
BINGHAMTON NY
13905-4178
US

IV. Provider business mailing address

161 RIVERSIDE DR STE 201
BINGHAMTON NY
13905-4178
US

V. Phone/Fax

Practice location:
  • Phone: 607-798-7169
  • Fax: 607-798-9204
Mailing address:
  • Phone: 607-798-7169
  • Fax: 607-798-9204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number030712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: