Provider Demographics
NPI:1962617704
Name:FISHER, TRAVIS LADEL (RDH)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:LADEL
Last Name:FISHER
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-2117
Mailing Address - Country:US
Mailing Address - Phone:406-275-4904
Mailing Address - Fax:406-275-4815
Practice Address - Street 1:5 4TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2117
Practice Address - Country:US
Practice Address - Phone:406-275-4904
Practice Address - Fax:406-275-4815
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD683124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist