Provider Demographics
NPI:1275578791
Name:FREDRICKSON, MALIA (DDS)
Entity Type:Individual
Prefix:
First Name:MALIA
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TRAILS END
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1738
Mailing Address - Country:US
Mailing Address - Phone:864-882-0620
Mailing Address - Fax:
Practice Address - Street 1:10229A CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0817
Practice Address - Country:US
Practice Address - Phone:864-882-0620
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3260Medicaid
SCZA9819Medicaid