Provider Demographics
NPI:1467654137
Name:FITCH, ROBERT GRAHAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GRAHAM
Last Name:FITCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2926
Mailing Address - Country:US
Mailing Address - Phone:270-753-1691
Mailing Address - Fax:
Practice Address - Street 1:1304 JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2926
Practice Address - Country:US
Practice Address - Phone:270-753-1691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY84821223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100017970Medicaid