Provider Demographics
NPI:1699166165
Name:FISHER, JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:FISHER
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 1:1925 EASTCHESTER RD APT 25H
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2107
Mailing Address - Country:US
Mailing Address - Phone:215-290-5670
Mailing Address - Fax:
Practice Address - Street 1:2920 HEMPSTEAD TPKE STE 2
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1402
Practice Address - Country:US
Practice Address - Phone:516-796-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY058657-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program