Provider Demographics
NPI:1568517779
Name:LANDGREBE, FREDERICK ARNOLD
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:ARNOLD
Last Name:LANDGREBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:F
Other - Middle Name:A
Other - Last Name:LANDGREBE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1008 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3762
Mailing Address - Country:US
Mailing Address - Phone:701-667-1933
Mailing Address - Fax:701-667-2115
Practice Address - Street 1:1008 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3762
Practice Address - Country:US
Practice Address - Phone:701-667-1933
Practice Address - Fax:701-667-2115
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40654Medicaid