Provider Demographics
NPI:1588636773
Name:CARPENTER, FRED WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:WILLIAM
Last Name:CARPENTER
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 1:1514 WHITE BEAR AVE
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1695
Mailing Address - Country:US
Mailing Address - Phone:651-771-7719
Mailing Address - Fax:651-776-2595
Practice Address - Street 1:1514 WHITE BEAR AVE
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1695
Practice Address - Country:US
Practice Address - Phone:651-771-7719
Practice Address - Fax:651-776-2595
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN88571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics