Provider Demographics
NPI:1972894061
Name:CARL B. FITZSIMMONS, DDS, PA
Entity type:Organization
Organization Name:CARL B. FITZSIMMONS, DDS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:BENTON
Authorized Official - Last Name:FITZSIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-577-9840
Mailing Address - Street 1:16795 COUNTY ROAD 24
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1201
Mailing Address - Country:US
Mailing Address - Phone:763-577-9840
Mailing Address - Fax:763-577-9843
Practice Address - Street 1:16795 COUNTY ROAD 24
Practice Address - Street 2:SUITE 6
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1201
Practice Address - Country:US
Practice Address - Phone:763-577-9840
Practice Address - Fax:763-577-9843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11044261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental