Provider Demographics
NPI:1346704061
Name:FRIDERES DENTAL LLC
Entity Type:Organization
Organization Name:FRIDERES DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:MATHIAS BAUER
Authorized Official - Last Name:FRIDERES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-549-2011
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-0010
Mailing Address - Country:US
Mailing Address - Phone:541-549-2011
Mailing Address - Fax:541-549-4787
Practice Address - Street 1:491 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-0197
Practice Address - Country:US
Practice Address - Phone:541-549-2011
Practice Address - Fax:541-549-4787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRIDERES DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty