Provider Demographics
NPI:1902805138
Name:FISCUS, ANDREW LIONEL (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:LIONEL
Last Name:FISCUS
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 1:3400 PENROSE PL
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1809
Mailing Address - Country:US
Mailing Address - Phone:303-442-5748
Mailing Address - Fax:303-442-5749
Practice Address - Street 1:3400 PENROSE PL
Practice Address - Street 2:SUITE 202
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1809
Practice Address - Country:US
Practice Address - Phone:303-442-5748
Practice Address - Fax:303-442-5749
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
CO81951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice