Provider Demographics
NPI:1245071661
Name:FISHER, JAKE ALEXANDER (DDS)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ALEXANDER
Last Name:FISHER
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 1:7660 36TH ST N APT 107
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-7582
Mailing Address - Country:US
Mailing Address - Phone:406-231-5212
Mailing Address - Fax:
Practice Address - Street 1:7101 HOFF ST
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-5645
Practice Address - Country:US
Practice Address - Phone:706-544-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001467-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist