Provider Demographics
NPI:1932769189
Name:FITZGERALD, JOHN (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:13804 WATCH HARBOUR CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2044
Mailing Address - Country:US
Mailing Address - Phone:804-291-8401
Mailing Address - Fax:
Practice Address - Street 1:26 BEE STREET MSC 507 DENTAL CLINIC ROOM 550
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:843-876-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014165381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice