Provider Demographics
NPI:1922256908
Name:FREDRICKSON, DANIEL AARON (DMD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:AARON
Last Name:FREDRICKSON
Suffix:
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 1:3877 PELL PL
Mailing Address - Street 2:#322
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-4143
Mailing Address - Country:US
Mailing Address - Phone:503-467-8895
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:NMCSD
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:503-467-8895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD91741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice