Provider Demographics
NPI:1235114679
Name:FITZGERALD, MIA W (DMD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:W
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 380
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-0380
Mailing Address - Country:US
Mailing Address - Phone:978-443-6081
Mailing Address - Fax:978-440-9425
Practice Address - Street 1:200 CONCORD RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-2352
Practice Address - Country:US
Practice Address - Phone:978-443-6081
Practice Address - Fax:978-440-9425
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist