Provider Demographics
NPI:1609948363
Name:FISHER, JACK COLEMAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:COLEMAN
Last Name:FISHER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:COLEMAN
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:8295 CORDOVA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2045
Mailing Address - Country:US
Mailing Address - Phone:901-433-9181
Mailing Address - Fax:901-433-9170
Practice Address - Street 1:8295 CORDOVA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2045
Practice Address - Country:US
Practice Address - Phone:901-433-9181
Practice Address - Fax:901-433-9170
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42751223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics