Provider Demographics
NPI:1801139662
Name:FITZGERALD, BRANDON MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W 57TH ST APT 463
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 W 57TH ST
Practice Address - Street 2:APT 463
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2937
Practice Address - Country:US
Practice Address - Phone:702-326-6745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0410051223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology