Provider Demographics
NPI:1962624312
Name:FITZGERALD, JOHN B III (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:FITZGERALD
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 MIDLAND CIR
Mailing Address - Street 2:
Mailing Address - City:ST DAVIDS
Mailing Address - State:PA
Mailing Address - Zip Code:19087-5002
Mailing Address - Country:US
Mailing Address - Phone:610-971-2121
Mailing Address - Fax:610-296-9993
Practice Address - Street 1:1201 W SWEDESFORD ROAD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312
Practice Address - Country:US
Practice Address - Phone:610-296-9990
Practice Address - Fax:610-296-9993
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024621L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist