Provider Demographics
NPI:1881845790
Name:FISCUS, GARY EARL (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EARL
Last Name:FISCUS
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 1:4565 QUAIL LAKES DRIVE
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209
Mailing Address - Country:US
Mailing Address - Phone:209-473-3990
Mailing Address - Fax:209-473-1725
Practice Address - Street 1:4565 QUAIL LAKES DRIVE
Practice Address - Street 2:SUITE A-2
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209
Practice Address - Country:US
Practice Address - Phone:209-473-3990
Practice Address - Fax:209-473-1725
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist