Provider Demographics
NPI:1811026206
Name:WOOD, FRED DICKSON III (DMD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:DICKSON
Last Name:WOOD
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1567
Mailing Address - Country:US
Mailing Address - Phone:570-724-9663
Mailing Address - Fax:570-724-2960
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1567
Practice Address - Country:US
Practice Address - Phone:570-724-9663
Practice Address - Fax:570-724-2960
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS015975L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice