Provider Demographics
NPI:1326130287
Name:RICH, FRED ELLIOT (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:ELLIOT
Last Name:RICH
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 667
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-0667
Mailing Address - Country:US
Mailing Address - Phone:315-668-6261
Mailing Address - Fax:315-668-3255
Practice Address - Street 1:653 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9105
Practice Address - Country:US
Practice Address - Phone:315-668-6261
Practice Address - Fax:315-668-3255
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35932122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist