Provider Demographics
NPI:1558496026
Name:FREDERICK, DONALD A III (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:A
Last Name:FREDERICK
Suffix:III
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:RR 1 BOX 289
Mailing Address - Street 2:
Mailing Address - City:HARVEYS LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:18618-9760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-1705
Practice Address - Country:US
Practice Address - Phone:570-829-2691
Practice Address - Fax:570-829-2790
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA19534-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA126020OtherUCCI PROVIDER ID#
PA156744OtherUNISON PROVIDER ID#