Provider Demographics
NPI:1578601449
Name:FREDRICKSON, BRENT CURTIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:CURTIS
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 1:1651 N DALE STREET
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117
Mailing Address - Country:US
Mailing Address - Phone:651-488-5888
Mailing Address - Fax:651-488-8425
Practice Address - Street 1:1651 N DALE STREET
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117
Practice Address - Country:US
Practice Address - Phone:651-488-5888
Practice Address - Fax:651-488-8425
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11125122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist