Provider Demographics
NPI:1912374075
Name:SAMMONS, FREDERICK JR (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
Last Name:SAMMONS
Suffix:JR
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-2059
Mailing Address - Country:US
Mailing Address - Phone:304-522-3512
Mailing Address - Fax:304-522-6233
Practice Address - Street 1:1040 20TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-2059
Practice Address - Country:US
Practice Address - Phone:304-522-3512
Practice Address - Fax:304-522-6233
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137863000Medicaid