Provider Demographics
NPI:1568468130
Name:FIDLER, MICHAEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:FIDLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:J
Other - Last Name:FIDLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:161 RIVERSIDE DR
Mailing Address - Street 2:STE 201
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4178
Mailing Address - Country:US
Mailing Address - Phone:607-798-7169
Mailing Address - Fax:607-798-9204
Practice Address - Street 1:161 RIVERSIDE DR
Practice Address - Street 2:STE 201
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4178
Practice Address - Country:US
Practice Address - Phone:607-798-7169
Practice Address - Fax:607-798-9204
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
NY0307121223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00554912Medicaid
NY00554912Medicaid