Provider Demographics
NPI:1376768176
Name:FREDERICK, DONALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:FREDERICK
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 1:4 HUNTINGTON CT
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2213
Mailing Address - Country:US
Mailing Address - Phone:732-542-7770
Mailing Address - Fax:732-542-4244
Practice Address - Street 1:288 STATE ROUTE 35 S
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2105
Practice Address - Country:US
Practice Address - Phone:732-542-7770
Practice Address - Fax:732-542-4244
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ119101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ11910OtherSTATE LICENSE NUMBER