Provider Demographics
NPI:1518085067
Name:FREDRICKSON, CARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
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 1:3200 MOWRY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1510
Mailing Address - Country:US
Mailing Address - Phone:510-792-1882
Mailing Address - Fax:510-792-4599
Practice Address - Street 1:3200 MOWRY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1510
Practice Address - Country:US
Practice Address - Phone:510-792-1882
Practice Address - Fax:510-792-4599
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA026638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist