Basic Information
| Provider Information | |||||||||
| NPI: | 1285624171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | MS 773-DENTAL CLINIC | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662040 | ||||||||
| FaxNumber: | 4142665677 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | MAIL STATION 773-DENTAL CLINIC | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662040 | ||||||||
| FaxNumber: | 4142665677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 025-001997 | IL | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 5127015 | WI | Y | Dental Providers | Dentist | Pediatric Dentistry | 122300000X | 019-025019 | IL | N | Dental Providers | Dentist |
No ID Information.