Provider Demographics
NPI:1013136746
Name:NICHOLAS A. FREDERICKA D.M.D. INC.
Entity Type:Organization
Organization Name:NICHOLAS A. FREDERICKA D.M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:FREDERICKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-652-6500
Mailing Address - Street 1:822 ROBBINS AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-2432
Mailing Address - Country:US
Mailing Address - Phone:330-652-6500
Mailing Address - Fax:330-652-6550
Practice Address - Street 1:822 ROBBINS AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2432
Practice Address - Country:US
Practice Address - Phone:330-652-6500
Practice Address - Fax:330-652-6550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300161401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH196764OtherUNITED CONCORDIA INS. ID#
OH0493729Medicaid
OH0493729Medicaid
OH196764OtherUNITED CONCORDIA INS. ID#