Provider Demographics
NPI:1194946079
Name:FISHBAUGH, KIRK RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:RICHARD
Last Name:FISHBAUGH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 TULIP LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6855
Mailing Address - Country:US
Mailing Address - Phone:920-434-1515
Mailing Address - Fax:920-434-7853
Practice Address - Street 1:2625 TULIP LN
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6855
Practice Address - Country:US
Practice Address - Phone:920-434-1515
Practice Address - Fax:920-434-7853
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4714-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice