Provider Demographics
NPI:1104830231
Name:SEVERSON, FREDERICK MONROE (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:MONROE
Last Name:SEVERSON
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NICOLLET
Mailing Address - State:MN
Mailing Address - Zip Code:56074-0009
Mailing Address - Country:US
Mailing Address - Phone:507-232-3481
Mailing Address - Fax:
Practice Address - Street 1:200 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NICOLLET
Practice Address - State:MN
Practice Address - Zip Code:56074-0009
Practice Address - Country:US
Practice Address - Phone:507-232-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN91881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice