Provider Demographics
NPI:1740255413
Name:FISH, JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:FISH
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:#4 HICKORY RIDGE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HILLSBORO
Mailing Address - State:MO
Mailing Address - Zip Code:63050
Mailing Address - Country:US
Mailing Address - Phone:636-789-3997
Mailing Address - Fax:636-789-3935
Practice Address - Street 1:#4 HICKORY RIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050
Practice Address - Country:US
Practice Address - Phone:636-789-3997
Practice Address - Fax:636-789-3935
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist