Provider Demographics
NPI:1629551098
Name:FISHER, ALYSIA MAE (RDH)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:MAE
Last Name:FISHER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 243RD AVE
Mailing Address - Street 2:
Mailing Address - City:LUCK
Mailing Address - State:WI
Mailing Address - Zip Code:54853-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 STATE ROAD 35
Practice Address - Street 2:
Practice Address - City:CENTURIA
Practice Address - State:WI
Practice Address - Zip Code:54824-9014
Practice Address - Country:US
Practice Address - Phone:715-646-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10140-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist