Healthcare Provider Details

I. General information

NPI: 1205822681
Provider Name (Legal Business Name): KEIFER LAYNE FISHER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 W BROADWAY ST
SPIRO OK
74959-2422
US

IV. Provider business mailing address

318 W BROADWAY ST
SPIRO OK
74959-2422
US

V. Phone/Fax

Practice location:
  • Phone: 918-962-2466
  • Fax: 918-962-4004
Mailing address:
  • Phone: 918-962-2466
  • Fax: 918-962-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4826
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: