Provider Demographics
NPI:1386322097
Name:FITZGIBBONS, EDEN MARIE (DDS)
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:MARIE
Last Name:FITZGIBBONS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 NE 107TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-1574
Mailing Address - Country:US
Mailing Address - Phone:816-605-0034
Mailing Address - Fax:816-399-5090
Practice Address - Street 1:506 NE 107TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-1574
Practice Address - Country:US
Practice Address - Phone:816-605-0034
Practice Address - Fax:816-399-5090
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20230237451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice