Provider Demographics
NPI:1760580849
Name:FITZGERALD, TIMOTHY ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:FITZGERALD
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 1:335 W JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2112
Mailing Address - Country:US
Mailing Address - Phone:309-833-2125
Mailing Address - Fax:
Practice Address - Street 1:335 W JACKSON STREET
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2112
Practice Address - Country:US
Practice Address - Phone:309-833-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist