Provider Demographics
NPI:1588218077
Name:FREDERIQUE, MALISSA (DDS)
Entity type:Individual
Prefix:MS
First Name:MALISSA
Middle Name:
Last Name:FREDERIQUE
Suffix:
Gender:
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 1:650 FULTON STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217
Mailing Address - Country:US
Mailing Address - Phone:718-596-9800
Mailing Address - Fax:718-855-5628
Practice Address - Street 1:BROOKLYN PLAZA MEDICAL CENTER, INC.
Practice Address - Street 2:650 FULTON STREET
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217
Practice Address - Country:US
Practice Address - Phone:718-596-9800
Practice Address - Fax:718-855-5628
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061360-011223G0001X
NY0613601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07959479Medicaid