=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467661850
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | J. WARD FITZPATRICK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 3RD AVE SUITE 3
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704-5806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-283-3300
-----------------------------------------------------
Fax | 570-331-7129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 3RD AVE SUITE 3
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704-5806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-283-3300
-----------------------------------------------------
Fax | 570-331-7129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DS026620L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------