Provider Demographics
NPI:1619081064
Name:FENDERSON, FREDERICK ANTHONY (DDS)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:ANTHONY
Last Name:FENDERSON
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 1:3150 CLEARWATER DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7131
Mailing Address - Country:US
Mailing Address - Phone:928-445-7051
Mailing Address - Fax:928-778-1731
Practice Address - Street 1:3150 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-445-7051
Practice Address - Fax:928-778-1731
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428201223X0400X
AZD-45661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ589393OtherACCESS