MEDICARE: J. WARD FITZPATRICK 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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1720331036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. WARD FITZPATRICK DDS

Provider Business Mailing Address
First Line	:	123 PIKE ST
Second Line	:
City	:	PORT JERVIS
State	:	NY
Zip	:	12771-1824
Country	:	US
Telephone Number	:	845-856-3311
Fax Number	:	845-856-5389

Provider Business Practice Location Address
First Line	:	123 PIKE ST
Second Line	:
City	:	PORT JERVIS
State	:	NY
Zip	:	12771-1824
Country	:	US
Telephone Number	:	845-856-3311
Fax Number	:	845-856-5389

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WARD FITZPATRICK
Credential	:	D.D.S.
Telephone Number	:	570-283-3300

Provider Enumeration Date	:	10/24/2012
Last Update Date	:	10/24/2012

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