Provider Demographics
NPI:1376766030
Name:FREDERICK, STEVEN MARSHALL (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MARSHALL
Last Name:FREDERICK
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 1:1190 W ASH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-4672
Mailing Address - Country:US
Mailing Address - Phone:970-674-0250
Mailing Address - Fax:970-674-1455
Practice Address - Street 1:1190 W ASH ST
Practice Address - Street 2:SUITE B
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-4672
Practice Address - Country:US
Practice Address - Phone:970-674-0250
Practice Address - Fax:970-674-1455
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO81021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice