Provider Demographics
NPI:1376612101
Name:FREIJ, RANDY (DDS)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:FREIJ
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 1:31393 W 13 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2297
Mailing Address - Country:US
Mailing Address - Phone:734-474-4703
Mailing Address - Fax:734-522-0534
Practice Address - Street 1:31393 W 13 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2297
Practice Address - Country:US
Practice Address - Phone:734-474-4703
Practice Address - Fax:734-522-0534
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010189291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901018929OtherLICENSE NUMBER