Provider Demographics
NPI:1356412415
Name:FITZGERALD, BETHANY K (DDS)
Entity type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:K
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BILODEAU CT
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1518
Mailing Address - Country:US
Mailing Address - Phone:802-862-6673
Mailing Address - Fax:
Practice Address - Street 1:157 RIVER ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:VT
Practice Address - Zip Code:05468-3607
Practice Address - Country:US
Practice Address - Phone:802-893-4734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT21401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009136Medicaid