Provider Demographics
NPI:1669453718
Name:FITCH, PHILLIP STEVEN (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:STEVEN
Last Name:FITCH
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 1:224 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3541
Mailing Address - Country:US
Mailing Address - Phone:507-345-3430
Mailing Address - Fax:507-345-4054
Practice Address - Street 1:224 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3541
Practice Address - Country:US
Practice Address - Phone:507-345-3430
Practice Address - Fax:507-345-4054
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND75421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice