Provider Demographics
NPI:1386813509
Name:FITZPATRICK ,MARY,DDS INC
Entity type:Organization
Organization Name:FITZPATRICK ,MARY,DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-527-4631
Mailing Address - Street 1:1601 MCHENRY VILLAGE WAY
Mailing Address - Street 2:STE 10-A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4307
Mailing Address - Country:US
Mailing Address - Phone:209-527-5727
Mailing Address - Fax:209-527-4626
Practice Address - Street 1:1601 MCHENRY VILLAGE WAY
Practice Address - Street 2:STE 10-A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4307
Practice Address - Country:US
Practice Address - Phone:209-527-5727
Practice Address - Fax:209-527-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty