Provider Demographics
NPI:1235295759
Name:DIEDRICHSEN, FRED J (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:DIEDRICHSEN
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 408
Mailing Address - Street 2:
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-0408
Mailing Address - Country:US
Mailing Address - Phone:308-995-8666
Mailing Address - Fax:308-995-2759
Practice Address - Street 1:130 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-0408
Practice Address - Country:US
Practice Address - Phone:308-995-8666
Practice Address - Fax:308-995-2759
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE40231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0577304OtherMEDICAID
NE47077556501OtherSATELLITE OFFICE IN NE
NE47077556500Medicaid
NE701754OtherDENTAL INSURANCE