Provider Demographics
NPI:1972663391
Name:FRIED, IVAN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:S
Last Name:FRIED
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 1:1700 REISTERSTOWN RD
Mailing Address - Street 2:POMONA SQUARE SUITE 203
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1416
Mailing Address - Country:US
Mailing Address - Phone:410-653-0091
Mailing Address - Fax:410-653-0092
Practice Address - Street 1:1700 REISTERSTOWN RD
Practice Address - Street 2:POMONA SQUARE SUITE 203
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-1416
Practice Address - Country:US
Practice Address - Phone:410-653-0091
Practice Address - Fax:410-653-0092
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD64071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics