Provider Demographics
NPI:1376616219
Name:THIELKE, FREDERICK LOWELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:LOWELL
Last Name:THIELKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 WALTON WAY EXT
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4507
Mailing Address - Country:US
Mailing Address - Phone:706-738-7129
Mailing Address - Fax:706-738-6684
Practice Address - Street 1:3643 WALTON WAY EXT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4507
Practice Address - Country:US
Practice Address - Phone:706-738-7129
Practice Address - Fax:706-738-6684
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA102491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice