Provider Demographics
NPI:1881790236
Name:FITZGERALD, PAUL D (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:FITZGERALD
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: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
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150
Practice Address - Country:US
Practice Address - Phone:870-942-2822
Practice Address - Fax:870-942-5816
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58181OtherBLUE CROSS BLUE SHIELD
AR835736OtherUNITED CONCORDIA