Provider Demographics
NPI:1659482891
Name:MARK A FITZGERALD DMD PC
Entity Type:Organization
Organization Name:MARK A FITZGERALD DMD PC
Other - Org Name:ALLATONNA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-382-5678
Mailing Address - Street 1:100 COURTYARD DRIVE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120
Mailing Address - Country:US
Mailing Address - Phone:770-382-5678
Mailing Address - Fax:770-382-1108
Practice Address - Street 1:100 COURTYARD DRIVE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120
Practice Address - Country:US
Practice Address - Phone:770-382-5678
Practice Address - Fax:770-382-1108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0107801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
277431OtherUNITED CONCORDIA CO INS