Provider Demographics
NPI:1730181579
Name:FISHBURN, CASEY GLENN (DMD)
Entity type:Individual
Prefix:DR
First Name:CASEY
Middle Name:GLENN
Last Name:FISHBURN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 HADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-2903
Mailing Address - Country:US
Mailing Address - Phone:918-682-5158
Mailing Address - Fax:
Practice Address - Street 1:2205 CHANDLER RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4626
Practice Address - Country:US
Practice Address - Phone:918-683-2291
Practice Address - Fax:918-683-2491
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice