MEDICARE: FISHER DENTAL CENTER

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	122300000X	Dentist	12781	MO
2	124Q00000X	Dental Hygienist
3	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1538275037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FISHER DENTAL CENTER

Provider Business Mailing Address
First Line	:	11634 W FLORISSANT AVENUE
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63033
Country	:	US
Telephone Number	:	314-837-9777
Fax Number	:	314-837-9778

Provider Business Practice Location Address
First Line	:	11634 W FLORISSANT AVENUE
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63033
Country	:	US
Telephone Number	:	314-837-9777
Fax Number	:	314-837-9778

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. OLLIE CHRISTOPHER FISHER
Credential	:	DMD
Telephone Number	:	374-837-9777

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	09/11/2025

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