Provider Demographics
NPI:1093890436
Name:DIDRIKSEN, PEDAR BRADEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PEDAR
Middle Name:BRADEN
Last Name:DIDRIKSEN
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 1:907 RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613
Mailing Address - Country:US
Mailing Address - Phone:319-277-7441
Mailing Address - Fax:319-553-0607
Practice Address - Street 1:11310 MANKLIN CREEK RD UNIT 5
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-4013
Practice Address - Country:US
Practice Address - Phone:410-208-2900
Practice Address - Fax:410-208-3285
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0255042Medicare ID - Type Unspecified