Provider Demographics
NPI:1811065527
Name:FITZPATRICK, MARY LOU (DDS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MC HENRY VILLAGE WAY
Mailing Address - Street 2:SUITE 10-A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-527-5727
Mailing Address - Fax:209-527-4626
Practice Address - Street 1:1601 MCHENRY VILLAGE WAY
Practice Address - Street 2:SUITE 10-A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4307
Practice Address - Country:US
Practice Address - Phone:209-527-5727
Practice Address - Fax:209-527-4626
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA396331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9366-01Medicare ID - Type UnspecifiedDENTCAL PROVIDER #