MEDICARE: RANDY R. FITZGERALD DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	6988	AZ

General Provider Information

NPI Number	:	1669549119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDY R. FITZGERALD DDS

Provider Business Mailing Address
First Line	:	4350 E RAY RD
Second Line	:	BUILDING 2 SUITE 110
City	:	PHOENIX
State	:	AZ
Zip	:	85044-4703
Country	:	US
Telephone Number	:	480-706-0777
Fax Number	:	480-706-0825

Provider Business Practice Location Address
First Line	:	4350 E RAY RD
Second Line	:	BUILDING 2 SUITE 110
City	:	PHOENIX
State	:	AZ
Zip	:	85044-4703
Country	:	US
Telephone Number	:	480-706-0777
Fax Number	:	480-706-0825

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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