Provider Demographics
NPI:1679805782
Name:FREDERICKS, SUSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 TOPANGA CANYON BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-2036
Mailing Address - Country:US
Mailing Address - Phone:818-346-3337
Mailing Address - Fax:
Practice Address - Street 1:6325 TOPANGA CANYON BLVD STE 402
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2036
Practice Address - Country:US
Practice Address - Phone:818-346-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice