Provider Demographics
NPI:1750858478
Name:FREDAL, THOMAS MICHAEL JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:FREDAL
Suffix:JR
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 1:45428 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5676
Mailing Address - Country:US
Mailing Address - Phone:586-731-8338
Mailing Address - Fax:586-731-6197
Practice Address - Street 1:45428 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5676
Practice Address - Country:US
Practice Address - Phone:586-731-8338
Practice Address - Fax:586-731-6197
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist