Provider Demographics
NPI:1366417594
Name:FISHMAN, ROSS H (DMD)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:H
Last Name:FISHMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W TOWN PL STE 106
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3662
Mailing Address - Country:US
Mailing Address - Phone:904-940-7990
Mailing Address - Fax:
Practice Address - Street 1:425 W TOWN PL STE 106
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3662
Practice Address - Country:US
Practice Address - Phone:904-940-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075770500Medicaid