Provider Demographics
NPI:1629490131
Name:HARRISBURG ORTHODONTICS ASSOC LLC
Entity Type:Organization
Organization Name:HARRISBURG ORTHODONTICS ASSOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:FREDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MAGD
Authorized Official - Phone:570-326-1481
Mailing Address - Street 1:3731 WALNUT ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-2555
Mailing Address - Country:US
Mailing Address - Phone:717-545-3187
Mailing Address - Fax:717-920-9402
Practice Address - Street 1:3731 WALNUT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-2555
Practice Address - Country:US
Practice Address - Phone:717-545-3187
Practice Address - Fax:717-920-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSD17415L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty