Provider Demographics
NPI:1609967694
Name:FISCHER, ELLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:FISCHER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:318 SATTLEY ST
Mailing Address - Street 2:PO BOX 55
Mailing Address - City:ROCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62563-9241
Mailing Address - Country:US
Mailing Address - Phone:217-498-3622
Mailing Address - Fax:
Practice Address - Street 1:318 SATTLEY ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62563-9241
Practice Address - Country:US
Practice Address - Phone:217-498-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5984-0151223G0001X
IL019.028607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33799500Medicaid