Provider Demographics
NPI:1386020170
Name:ROBERT HERBERT FREDRICKSON
Entity Type:Organization
Organization Name:ROBERT HERBERT FREDRICKSON
Other - Org Name:ROBERT H FREDRICKSON DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:FREDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:570-326-6170
Mailing Address - Street 1:1124 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2124
Mailing Address - Country:US
Mailing Address - Phone:570-326-6170
Mailing Address - Fax:
Practice Address - Street 1:1124 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2124
Practice Address - Country:US
Practice Address - Phone:570-326-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017415L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4590250001Medicare NSC