Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 0013611 | TX |
NPI | 1598794133 |
---|---|
Provider Name | Mr. Stanley W Fitzer |
First Address | Fort Worth, TX 76104-7644 |
Second Address | Fort Worth, TX 76104-7644 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0013611 | DDS LICENSE (01) | TX |