Provider Demographics
NPI:1396831871
Name:FREEDUS, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FREEDUS
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 1:2535 LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:DELANSON
Mailing Address - State:NY
Mailing Address - Zip Code:12053
Mailing Address - Country:US
Mailing Address - Phone:518-864-5032
Mailing Address - Fax:
Practice Address - Street 1:53 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820
Practice Address - Country:US
Practice Address - Phone:607-432-3564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0288891223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00534354Medicaid