Provider Demographics
NPI:1528090511
Name:FIESE, RICHARD LAWRENCE (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LAWRENCE
Last Name:FIESE
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 1:105 CO RT 45 A
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126
Mailing Address - Country:US
Mailing Address - Phone:315-343-6160
Mailing Address - Fax:315-343-8556
Practice Address - Street 1:105 CO RT 45 A
Practice Address - Street 2:SUITE 100
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-343-6160
Practice Address - Fax:315-343-8556
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0407871122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01046088Medicaid
NY01046088Medicaid
T68372Medicare UPIN