Provider Demographics
NPI:1588218077
Name:FREDERIQUE, MALISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALISSA
Middle Name:
Last Name:FREDERIQUE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MALISSA
Other - Middle Name:
Other - Last Name:FREDERIQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8268 164TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1104
Mailing Address - Country:US
Mailing Address - Phone:347-733-5984
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1104
Practice Address - Country:US
Practice Address - Phone:347-733-5984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program