Provider Demographics
NPI:1649601915
Name:FREDERICK, RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:FREDERICK
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 1:937 E PALMDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4711
Mailing Address - Country:US
Mailing Address - Phone:661-947-7737
Mailing Address - Fax:661-947-0522
Practice Address - Street 1:937 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4711
Practice Address - Country:US
Practice Address - Phone:661-947-7737
Practice Address - Fax:661-947-0522
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist