Provider Demographics
NPI:1790875847
Name:REA, FRED DEE (DDS)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:DEE
Last Name:REA
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 1:806 MEDICAL CIRCLE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5110
Mailing Address - Country:US
Mailing Address - Phone:903-236-7023
Mailing Address - Fax:903-236-7723
Practice Address - Street 1:806 MEDICAL CIRCLE DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5110
Practice Address - Country:US
Practice Address - Phone:903-236-7023
Practice Address - Fax:903-236-7723
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123171223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics