Provider Demographics
NPI:1639160658
Name:FISHER, LARRY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ALAN
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 1:1945 W WILSON AVE
Mailing Address - Street 2:SUITE 2112
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5255
Mailing Address - Country:US
Mailing Address - Phone:773-561-4508
Mailing Address - Fax:773-561-4508
Practice Address - Street 1:1945 W WILSON AVE
Practice Address - Street 2:SUITE 2112
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5255
Practice Address - Country:US
Practice Address - Phone:773-561-4508
Practice Address - Fax:773-561-4508
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0154841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164971Medicaid