Provider Demographics
NPI:1770788515
Name:FISCHER, LAURIE ELLEN (RDH)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELLEN
Last Name:FISCHER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 LITTLE SWISS PL
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-4924
Mailing Address - Country:US
Mailing Address - Phone:920-469-2705
Mailing Address - Fax:
Practice Address - Street 1:2740 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4966
Practice Address - Country:US
Practice Address - Phone:920-498-5469
Practice Address - Fax:920-498-6890
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4904016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist