Provider Demographics
NPI:1427017979
Name:FREDRICKSON, JACK C (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:C
Last Name:FREDRICKSON
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 1:2061 BRYCE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-8352
Mailing Address - Country:US
Mailing Address - Phone:928-855-6505
Mailing Address - Fax:
Practice Address - Street 1:1930 MESQUITE AVE
Practice Address - Street 2:STE. 8
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5674
Practice Address - Country:US
Practice Address - Phone:928-855-4347
Practice Address - Fax:928-855-6894
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice