Provider Demographics
NPI:1649550260
Name:FOGARTY, CHRISTY JO (RDH, ADT)
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:JO
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:RDH, ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 BROADWAY ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2164
Mailing Address - Country:US
Mailing Address - Phone:612-746-1530
Mailing Address - Fax:612-746-1531
Practice Address - Street 1:636 BROADWAY ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2164
Practice Address - Country:US
Practice Address - Phone:612-746-1530
Practice Address - Fax:612-746-1531
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH5961124Q00000X
MNDT02125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist