Provider Demographics
NPI: | 1376662619 |
---|---|
Name: | D FITZGERALD M PETRELLI DMD PC |
Entity Type: | Organization |
Organization Name: | D FITZGERALD M PETRELLI DMD PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DANIEL |
Authorized Official - Middle Name: | B |
Authorized Official - Last Name: | FITZGERALD |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 781-438-1995 |
Mailing Address - Street 1: | 112 MAIN STREET |
Mailing Address - Street 2: | |
Mailing Address - City: | STONEHAM |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02180 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 781-438-1995 |
Mailing Address - Fax: | 781-438-6378 |
Practice Address - Street 1: | 112 MAIN STREET |
Practice Address - Street 2: | |
Practice Address - City: | STONEHAM |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02180 |
Practice Address - Country: | US |
Practice Address - Phone: | 781-438-1995 |
Practice Address - Fax: | 781-438-6378 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-28 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 014305 | 122300000X |
MA | 016175 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |