Provider Demographics
NPI:1801014410
Name:FREDRICK DENTAL, PA
Entity Type:Organization
Organization Name:FREDRICK DENTAL, PA
Other - Org Name:JUPITER FARMS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:FREDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-743-6700
Mailing Address - Street 1:10156 W INDIANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-4707
Mailing Address - Country:US
Mailing Address - Phone:561-743-6700
Mailing Address - Fax:561-743-9314
Practice Address - Street 1:10156 W INDIANTOWN RD
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33478-4707
Practice Address - Country:US
Practice Address - Phone:561-743-6700
Practice Address - Fax:561-743-9314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN143001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty