MEDICARE: EDEN MARIE FITZGIBBONS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2023023745	MO

General Provider Information

NPI Number	:	1386322097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDEN MARIE FITZGIBBONS DDS

Provider Business Mailing Address
First Line	:	506 NE 107TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-1574
Country	:	US
Telephone Number	:	816-605-0034
Fax Number	:	816-399-5090

Provider Business Practice Location Address
First Line	:	506 NE 107TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-1574
Country	:	US
Telephone Number	:	816-605-0034
Fax Number	:	816-399-5090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2023
Last Update Date	:	07/11/2023

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