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General NPI Number Information
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NPI Number | 1063526796
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Entity Type | Individual
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Provider Name | FRED M FITZPATRICK D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 690 N IL ROUTE 31
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City | CRYSTAL LAKE
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State | IL
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Zip | 60012-3790
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Country | US
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Telephone | 815-459-2727
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Fax |
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Provider Business Mailing Address
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Address Line | 651 WOODLAND DR
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-5214
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Country | US
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Telephone | 815-459-9230
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | A13595
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License Number State | IL
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