Provider Demographics
NPI:1720140437
Name:FIEDLER, JACK MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:FIEDLER
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 1:149 MAIN STREET S
Mailing Address - Street 2:BOX 547
Mailing Address - City:HECTOR
Mailing Address - State:MN
Mailing Address - Zip Code:55342
Mailing Address - Country:US
Mailing Address - Phone:320-848-2611
Mailing Address - Fax:
Practice Address - Street 1:149 MAIN STREET S
Practice Address - Street 2:BOX 547
Practice Address - City:HECTOR
Practice Address - State:MN
Practice Address - Zip Code:55342
Practice Address - Country:US
Practice Address - Phone:320-848-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND123731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice