Healthcare Provider Details

I. General information

NPI: 1407070642
Provider Name (Legal Business Name): BRIAN DOUGLAS FITZPATRICK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E FONTANERO ST
COLORADO SPRINGS CO
80907-7529
US

IV. Provider business mailing address

245 RAVENGLASS WAY
COLORADO SPRINGS CO
80906-7970
US

V. Phone/Fax

Practice location:
  • Phone: 719-475-9023
  • Fax:
Mailing address:
  • Phone: 719-538-8367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD7793
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: