Provider Demographics
NPI:1982908000
Name:JACK M. FIEDLER, D.D.S.,P.A.
Entity type:Organization
Organization Name:JACK M. FIEDLER, D.D.S.,P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:M
Authorized Official - Last Name:FIEDLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-848-2611
Mailing Address - Street 1:150 GREENWOOD AVE W
Mailing Address - Street 2:BOX 547
Mailing Address - City:HECTOR
Mailing Address - State:MN
Mailing Address - Zip Code:55342
Mailing Address - Country:US
Mailing Address - Phone:320-848-2611
Mailing Address - Fax:320-848-2611
Practice Address - Street 1:150 GREENWOOD AVE W
Practice Address - Street 2:BOX 547
Practice Address - City:HECTOR
Practice Address - State:MN
Practice Address - Zip Code:55342
Practice Address - Country:US
Practice Address - Phone:320-848-2611
Practice Address - Fax:320-848-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND123731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty