Provider Demographics
NPI:1528205317
Name:FISH, MAIJA ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAIJA
Middle Name:ANNE
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 1:3001 6TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60088-2833
Mailing Address - Country:US
Mailing Address - Phone:847-688-2100
Mailing Address - Fax:
Practice Address - Street 1:3001 6TH ST
Practice Address - Street 2:STE A
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60088-2833
Practice Address - Country:US
Practice Address - Phone:847-688-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X122300000X
WI6359-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist