Provider Demographics
NPI:1174676589
Name:FREDERICK, GLENN M
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:
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 487
Mailing Address - Street 2:
Mailing Address - City:CANTERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06331-0487
Mailing Address - Country:US
Mailing Address - Phone:860-608-2334
Mailing Address - Fax:
Practice Address - Street 1:37 S CANTERBURY RD
Practice Address - Street 2:
Practice Address - City:CANTERBURY
Practice Address - State:CT
Practice Address - Zip Code:06331-1520
Practice Address - Country:US
Practice Address - Phone:860-546-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT50931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice