Provider Demographics
NPI:1730645078
Name:FISHER, OLIVIA RAYE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RAYE
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 POND VIEW DR STE 2
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-2507
Mailing Address - Country:US
Mailing Address - Phone:319-459-1975
Mailing Address - Fax:
Practice Address - Street 1:550 POND VIEW DR STE 2
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-2507
Practice Address - Country:US
Practice Address - Phone:319-459-1975
Practice Address - Fax:319-335-7451
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA098701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics