Provider Demographics
NPI:1073687323
Name:FREESEMAN, MICHAEL PAUL (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PAUL
Last Name:FREESEMAN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-2141
Mailing Address - Country:US
Mailing Address - Phone:319-234-4486
Mailing Address - Fax:319-232-4913
Practice Address - Street 1:847 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-2141
Practice Address - Country:US
Practice Address - Phone:319-234-4486
Practice Address - Fax:319-232-4913
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0007948Medicaid