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General NPI Number Information
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NPI Number | 1801809793
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Entity Type | Organization
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Legal Business Name | RICHARD FIESE ORAL & MAXILLOFACIAL SURGEON PC
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 105 CO RT 45A SUITE 100
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City | OSWEGO
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State | NY
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Zip | 13126
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Country | US
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Telephone | 315-343-6160
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Fax | 315-343-8556
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Provider Business Mailing Address
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Address Line | 105 CO RT 45A SUITE 100
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City | OSWEGO
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State | NY
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Zip | 13126
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Country | US
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Telephone | 315-343-6160
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Fax | 315-343-8556
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD L FIESE
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Credential | DMD
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Telephone | 315-343-6160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0407871
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License Number State | NY
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