Provider Demographics
NPI:1154310928
Name:FREIDLINE, CLIFFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:
Last Name:FREIDLINE
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 1:1208 SIERRA LARGA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-6509
Mailing Address - Country:US
Mailing Address - Phone:505-275-2777
Mailing Address - Fax:
Practice Address - Street 1:1208 SIERRA LARGA DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-6509
Practice Address - Country:US
Practice Address - Phone:505-275-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9177816Medicaid