Provider Demographics
NPI:1194856872
Name:FERGUSON, FRED SHAKESPEARE (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:SHAKESPEARE
Last Name:FERGUSON
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 1:10 BRAEMER RD
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3905
Mailing Address - Country:US
Mailing Address - Phone:631-751-3901
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK DENTAL ASSOCIATES
Practice Address - Street 2:SULLIVAN HALL RM 170
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-632-8971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0318041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00675654Medicaid