Provider Demographics
NPI:1477870665
Name:FREDRICK EDWIN STUART DDS, INC.
Entity Type:Organization
Organization Name:FREDRICK EDWIN STUART DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-842-0538
Mailing Address - Street 1:8781 VAN NUYS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-2401
Mailing Address - Country:US
Mailing Address - Phone:818-893-2716
Mailing Address - Fax:818-994-4117
Practice Address - Street 1:8781 VAN NUYS BLVD FL 2
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-2401
Practice Address - Country:US
Practice Address - Phone:818-893-2716
Practice Address - Fax:818-994-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-27
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty