Healthcare Provider Details

I. General information

NPI: 1881803179
Provider Name (Legal Business Name): JAMES P. FITZGERALD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SOUTH RD
SOMERS CT
06071-2160
US

IV. Provider business mailing address

48 SOUTH RD
SOMERS CT
06071-2160
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-0781
  • Fax:
Mailing address:
  • Phone: 860-749-0781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number08917
License Number StateCT

VIII. Authorized Official

Name: DR. JAMES PATRICK FITZGERALD
Title or Position: OWNER
Credential: D.M.D
Phone: 860-749-0781