Provider Demographics
NPI:1396846010
Name:FITZSIMMONS, CARL BENTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:BENTON
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16795 COUNTY ROAD 24 STE 6
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1202
Mailing Address - Country:US
Mailing Address - Phone:763-577-9840
Mailing Address - Fax:763-577-9843
Practice Address - Street 1:16795 COUNTY ROAD 24 STE 6
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447
Practice Address - Country:US
Practice Address - Phone:763-577-9840
Practice Address - Fax:763-533-2034
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11044122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist