Provider Demographics
NPI:1285837823
Name:FREDRICKSON, KRISTINA NICHOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:NICHOLE
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 1:720 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4539
Mailing Address - Country:US
Mailing Address - Phone:906-774-5087
Mailing Address - Fax:
Practice Address - Street 1:720 EAST BLVD
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4539
Practice Address - Country:US
Practice Address - Phone:906-774-5087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice