Provider Demographics
NPI:1730243213
Name:FITZGERALD, PATRICK IAN (DDS)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:IAN
Last Name:FITZGERALD
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 1:350 S NORTHWEST HWY
Mailing Address - Street 2:SUITE 116
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4216
Mailing Address - Country:US
Mailing Address - Phone:847-823-4161
Mailing Address - Fax:847-823-4163
Practice Address - Street 1:350 S NORTHWEST HWY
Practice Address - Street 2:SUITE 116
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4216
Practice Address - Country:US
Practice Address - Phone:847-823-4161
Practice Address - Fax:847-823-4163
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025826122300000X
IL0210021861223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist