Healthcare Provider Details

I. General information

NPI: 1124216304
Provider Name (Legal Business Name): STEPHEN D FISHER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RIVERVIEW DR
POTSDAM NY
13676-2090
US

IV. Provider business mailing address

1 RIVERVIEW DR
POTSDAM NY
13676-2090
US

V. Phone/Fax

Practice location:
  • Phone: 315-265-2896
  • Fax: 315-265-1035
Mailing address:
  • Phone: 315-265-2896
  • Fax: 315-265-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number032526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: