Provider Demographics
NPI:1518305838
Name:FISH, DIANE MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:FISH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 MARK AVE N
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-1030
Mailing Address - Country:US
Mailing Address - Phone:218-280-3324
Mailing Address - Fax:
Practice Address - Street 1:1670 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1201
Practice Address - Country:US
Practice Address - Phone:651-925-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-09
Last Update Date:2013-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN132201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice