Provider Demographics
NPI:1942990916
Name:FISK, JEFFREY (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FISK
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 1:221 E SOMERSET CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-4968
Mailing Address - Country:US
Mailing Address - Phone:606-451-1448
Mailing Address - Fax:
Practice Address - Street 1:221 E SOMERSET CHURCH RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-4968
Practice Address - Country:US
Practice Address - Phone:606-451-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics