Provider Demographics
NPI:1396191268
Name:MACKERT, FREDERICA (DDS)
Entity Type:Individual
Prefix:
First Name:FREDERICA
Middle Name:
Last Name:MACKERT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 GROVE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4561
Mailing Address - Country:US
Mailing Address - Phone:425-761-7354
Mailing Address - Fax:
Practice Address - Street 1:520 N 12TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5064
Practice Address - Country:US
Practice Address - Phone:804-828-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60757254122300000X
VA0411000065122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist