Provider Demographics
NPI:1376645507
Name:FREDERICKSBURG DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:FREDERICKSBURG DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-865-3457
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:120 SOUTH TAN STREET
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17026
Mailing Address - Country:US
Mailing Address - Phone:717-865-3457
Mailing Address - Fax:717-865-2101
Practice Address - Street 1:120 SOUTH TAN STREET
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:PA
Practice Address - Zip Code:17026
Practice Address - Country:US
Practice Address - Phone:717-865-3457
Practice Address - Fax:717-865-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25124L122300000X
PA28749L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty