Provider Demographics
NPI:1073122016
Name:FREDERICKSON, ANN (RDH, BSDH)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:RDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9851 S HOMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3041
Mailing Address - Country:US
Mailing Address - Phone:708-203-8046
Mailing Address - Fax:
Practice Address - Street 1:9851 S HOMAN AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3041
Practice Address - Country:US
Practice Address - Phone:708-203-8046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.009503124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist