Provider Demographics
NPI:1750604070
Name:PAUL D FITZGERALD, DDS
Entity type:Organization
Organization Name:PAUL D FITZGERALD, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-942-2822
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-0116
Mailing Address - Country:US
Mailing Address - Phone:870-942-2822
Mailing Address - Fax:870-942-5816
Practice Address - Street 1:209 W HOLLY ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-2425
Practice Address - Country:US
Practice Address - Phone:870-942-2822
Practice Address - Fax:870-942-5816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180074631Medicaid