Provider Demographics
NPI:1497799647
Name:RODEMS, FRED (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:RODEMS
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 1:22 S BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1239
Mailing Address - Country:US
Mailing Address - Phone:716-592-9269
Mailing Address - Fax:
Practice Address - Street 1:1947 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3339
Practice Address - Country:US
Practice Address - Phone:716-675-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY365531223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00832155Medicaid
NY00020919401OtherUNIVERA HEALTHCARE
NY00020919401OtherUNIVERA HEALTHCARE
NYBB9554Medicare PIN
NY00832155Medicaid