Provider Demographics
NPI:1114225141
Name:WALDSCHMIDT, FREDERICK P (DDS)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:P
Last Name:WALDSCHMIDT
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 1:750 ALMAR PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2315
Mailing Address - Country:US
Mailing Address - Phone:815-932-5221
Mailing Address - Fax:815-932-5269
Practice Address - Street 1:750 ALMAR PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2315
Practice Address - Country:US
Practice Address - Phone:815-932-5221
Practice Address - Fax:815-932-5269
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0193551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice