Provider Demographics
NPI:1558350348
Name:FREDERICKS, HAROLD EDWIN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:EDWIN
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 HARDING RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2118
Mailing Address - Country:US
Mailing Address - Phone:615-269-0485
Mailing Address - Fax:
Practice Address - Street 1:4515 HARDING RD
Practice Address - Street 2:SUITE 111
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205-2118
Practice Address - Country:US
Practice Address - Phone:615-269-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS32271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0016290Medicaid