Provider Demographics
NPI:1760563910
Name:FISTER, JEFFREY S (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:FISTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-404-8200
Mailing Address - Fax:207-975-0435
Practice Address - Street 1:1048 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3016
Practice Address - Country:US
Practice Address - Phone:207-404-8100
Practice Address - Fax:207-947-0435
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN27391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME115550000Medicaid
ME2739OtherSTATE LICENSE
ME2739OtherSTATE LICENSE