MEDICARE: DR. MICHAEL PATRICK FOGARTY D.D.S.

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	122300000X	Dentist	051577	NY

General Provider Information

NPI Number	:	1790760510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL PATRICK FOGARTY D.D.S.

Provider Business Mailing Address
First Line	:	26 LONSDALE DR
Second Line	:
City	:	SOUTH PLAINFIELD
State	:	NJ
Zip	:	07080-2128
Country	:	US
Telephone Number	:	908-753-8266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2413
Country	:	US
Telephone Number	:	718-981-1800
Fax Number	:

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/08/2007

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