Provider Demographics
NPI:1003237512
Name:PAUL A. FREDRIKSON, D.D.S., P.C.
Entity Type:Organization
Organization Name:PAUL A. FREDRIKSON, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREDRIKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:701-280-0088
Mailing Address - Street 1:3011 25TH ST S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6162
Mailing Address - Country:US
Mailing Address - Phone:701-280-0088
Mailing Address - Fax:701-293-5602
Practice Address - Street 1:3011 25TH ST S
Practice Address - Street 2:SUITE 1
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6162
Practice Address - Country:US
Practice Address - Phone:701-280-0088
Practice Address - Fax:701-293-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40631Medicaid