Provider Demographics
NPI:1629401575
Name:FRIDERES, TREVOR MATHIAS BAUER (DMD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:MATHIAS BAUER
Last Name:FRIDERES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:TREVOR
Other - Middle Name:MATHIAS
Other - Last Name:FRIDERES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-1027
Mailing Address - Country:US
Mailing Address - Phone:541-549-9486
Mailing Address - Fax:541-549-9110
Practice Address - Street 1:410 E CASCADE AVE
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759
Practice Address - Country:US
Practice Address - Phone:541-549-9486
Practice Address - Fax:541-549-9110
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD105771223G0001X
WADE60394053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist