Provider Demographics
NPI:1306050117
Name:FISH, ROBERT H
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:FISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 MAIN STREET, SUITE 101
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040
Mailing Address - Country:US
Mailing Address - Phone:860-646-1704
Mailing Address - Fax:860-649-2661
Practice Address - Street 1:945 MAIN STREET, SUITE 101
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:860-646-1704
Practice Address - Fax:860-649-2661
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT45901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice