Provider Demographics
NPI:1992373476
Name:FISTLER, GRACEN LEE
Entity Type:Individual
Prefix:
First Name:GRACEN
Middle Name:LEE
Last Name:FISTLER
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 1:2441 21ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5582
Mailing Address - Country:US
Mailing Address - Phone:270-798-8751
Mailing Address - Fax:
Practice Address - Street 1:2441 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5582
Practice Address - Country:US
Practice Address - Phone:270-798-8751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10644122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist