Provider Demographics
NPI:1629241161
Name:FISHER, SANDRA G (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:G
Last Name:FISHER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:JEAN
Other - Last Name:GRABOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:191 WILDWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045
Mailing Address - Country:US
Mailing Address - Phone:847-778-3196
Mailing Address - Fax:
Practice Address - Street 1:4235 W NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639
Practice Address - Country:US
Practice Address - Phone:773-276-3360
Practice Address - Fax:773-276-4032
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019244661223G0001X
MN092921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
101582OtherDORAL PAYER ID
1005544OtherDORAL PROVIDER ID