Provider Demographics
NPI:1568557114
Name:JEFFREY W. FISK, D.M.D, P.S.C
Entity Type:Organization
Organization Name:JEFFREY W. FISK, D.M.D, P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FISK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-451-1448
Mailing Address - Street 1:221 EAST SOMERSET CHURCH ROAD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-451-1448
Mailing Address - Fax:606-451-8269
Practice Address - Street 1:221 EAST SOMERSET CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-451-1448
Practice Address - Fax:606-451-8269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60001179Medicaid