Provider Demographics
NPI:1962569012
Name:FISHER, JACK
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:FISHER
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 1:2555 N MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-267-2674
Mailing Address - Fax:414-562-8435
Practice Address - Street 1:8200 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-2552
Practice Address - Country:US
Practice Address - Phone:414-267-2674
Practice Address - Fax:414-562-8435
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice