Provider Demographics
NPI:1063526796
Name:FITZPATRICK, FRED M (DDS)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:M
Last Name:FITZPATRICK
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 1:651 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5214
Mailing Address - Country:US
Mailing Address - Phone:815-459-9230
Mailing Address - Fax:
Practice Address - Street 1:690 N IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3790
Practice Address - Country:US
Practice Address - Phone:815-459-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA135951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry