Provider Demographics
NPI:1376662619
Name:D FITZGERALD M PETRELLI DMD PC
Entity type:Organization
Organization Name:D FITZGERALD M PETRELLI DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-438-1995
Mailing Address - Street 1:112 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180
Mailing Address - Country:US
Mailing Address - Phone:781-438-1995
Mailing Address - Fax:781-438-6378
Practice Address - Street 1:112 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180
Practice Address - Country:US
Practice Address - Phone:781-438-1995
Practice Address - Fax:781-438-6378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA016175122300000X
MA014305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty