Provider Demographics
NPI:1801809793
Name:RICHARD FIESE ORAL & MAXILLOFACIAL SURGEON PC
Entity type:Organization
Organization Name:RICHARD FIESE ORAL & MAXILLOFACIAL SURGEON PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:FIESE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:315-343-6160
Mailing Address - Street 1:105 CO RT 45A
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126
Mailing Address - Country:US
Mailing Address - Phone:315-343-6160
Mailing Address - Fax:315-343-8556
Practice Address - Street 1:105 CO RT 45A
Practice Address - Street 2:SUITE 100
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-343-6160
Practice Address - Fax:315-343-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0407871122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01046088Medicaid
T68372Medicare UPIN
51687AMedicare ID - Type Unspecified