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General NPI Number Information
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NPI Number | 1396716619
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Entity Type | Individual
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Provider Name | DALLAS DUSTIN FITZGERALD O.D.
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Gender | Male
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Dates
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Enumeration Date | 01/27/2006
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Last Update Date | 05/28/2008
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Provider Practice Location Address
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Address Line | 1605 S MAIN ST WAL-MART VISION CENTER
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City | MARYVILLE
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State | MO
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Zip | 64468-2611
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Country | US
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Telephone | 660-562-0215
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Fax | 660-562-0217
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Provider Business Mailing Address
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Address Line | 19738 SUNSET RDG
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City | SAINT JOSEPH
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State | MO
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Zip | 64505-8560
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Country | US
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Telephone | 816-662-9222
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | T03343
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License Number State | MO
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