Provider Demographics
NPI:1629420773
Name:FISHER, JAKE DOUGLAS (DDS)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:DOUGLAS
Last Name:FISHER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N 82ND PLZ
Mailing Address - Street 2:APT 8
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3591
Mailing Address - Country:US
Mailing Address - Phone:308-530-9516
Mailing Address - Fax:
Practice Address - Street 1:4400 EMILE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-0600
Practice Address - Country:US
Practice Address - Phone:402-559-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist