MEDICARE: DR. MARY M FISHER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12990	MI

General Provider Information

NPI Number	:	1508869058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY M FISHER DDS

Provider Business Mailing Address
First Line	:	6010 W MAPLE RD
Second Line	:	STE 210
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-4406
Country	:	US
Telephone Number	:	248-932-8980
Fax Number	:	248-932-2281

Provider Business Practice Location Address
First Line	:	6010 W MAPLE RD
Second Line	:	STE 210
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-4406
Country	:	US
Telephone Number	:	248-932-8980
Fax Number	:	248-419-6124

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2005
Last Update Date	:	03/24/2015

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