Provider Demographics
NPI:1104954403
Name:FITZGIBBONS, KELLY A (DMD)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:FITZGIBBONS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 316
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14231
Mailing Address - Country:US
Mailing Address - Phone:713-204-5838
Mailing Address - Fax:716-632-2963
Practice Address - Street 1:2 CELLU DRIVE
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063
Practice Address - Country:US
Practice Address - Phone:603-595-4200
Practice Address - Fax:603-689-7150
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3471122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist