Provider Demographics
NPI:1679029243
Name:FITZGERALD, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 PULASKY HWY.
Mailing Address - Street 2:SUITE2
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2057 PULASKY HWY.
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901
Practice Address - Country:US
Practice Address - Phone:410-287-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3597124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3579Medicaid