Provider Demographics
NPI:1740371251
Name:FITZER, STEPHEN RICHARD (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RICHARD
Last Name:FITZER
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 1:620 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3920
Mailing Address - Country:US
Mailing Address - Phone:740-354-5716
Mailing Address - Fax:740-355-0181
Practice Address - Street 1:620 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3920
Practice Address - Country:US
Practice Address - Phone:740-354-5716
Practice Address - Fax:740-355-0181
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH154261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0336032Medicaid