Provider Demographics
NPI:1376923482
Name:FREDERICKS, DAVID J (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:FREDERICKS
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 1:1 ASPETUCK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2842
Mailing Address - Country:US
Mailing Address - Phone:860-355-4137
Mailing Address - Fax:860-355-4139
Practice Address - Street 1:1 ASPETUCK AVE
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2842
Practice Address - Country:US
Practice Address - Phone:860-355-4137
Practice Address - Fax:860-355-4139
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0116301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice