Provider Demographics
NPI:1285624171
Name:FISHER, SHANE A (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:A
Last Name:FISHER
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 NW 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-3702
Mailing Address - Country:US
Mailing Address - Phone:773-577-7667
Mailing Address - Fax:
Practice Address - Street 1:819 NE 26TH ST
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1239
Practice Address - Country:US
Practice Address - Phone:954-564-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-025019122300000X
IL025-0019971223P0221X
WI51270151223P0221X
FLDN298341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist