Provider Demographics
NPI:1205822681
Name:FISHER, KEIFER LAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEIFER
Middle Name:LAYNE
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 1:318 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPIRO
Mailing Address - State:OK
Mailing Address - Zip Code:74959-2422
Mailing Address - Country:US
Mailing Address - Phone:918-962-2466
Mailing Address - Fax:918-962-4004
Practice Address - Street 1:318 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPIRO
Practice Address - State:OK
Practice Address - Zip Code:74959-2422
Practice Address - Country:US
Practice Address - Phone:918-962-2466
Practice Address - Fax:918-962-4004
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK48261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100670270AMedicaid
OK4826OtherOKLAHOMA DENTAL LICENSE