Provider Demographics
NPI:1578565933
Name:FITZNER, C. BERNARD JR (DDS, MAGD)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:BERNARD
Last Name:FITZNER
Suffix:JR
Gender:M
Credentials:DDS, MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-2861
Mailing Address - Country:US
Mailing Address - Phone:505-461-1670
Mailing Address - Fax:505-461-6404
Practice Address - Street 1:501 S 2ND ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-2861
Practice Address - Country:US
Practice Address - Phone:505-461-1670
Practice Address - Fax:505-461-6404
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD9921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM105950Medicaid
NM00082651Medicaid