Provider Demographics
NPI:1962765453
Name:TREAVOR D FISHER, DDS, LLC
Entity type:Organization
Organization Name:TREAVOR D FISHER, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TREAVOR
Authorized Official - Middle Name:D
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-554-4734
Mailing Address - Street 1:470 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2243
Mailing Address - Country:US
Mailing Address - Phone:541-269-2100
Mailing Address - Fax:
Practice Address - Street 1:470 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2243
Practice Address - Country:US
Practice Address - Phone:541-269-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD93401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty