Provider Demographics
NPI:1245369776
Name:FREDRICKSON, DENNIS (DMD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:
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 1:242 SOUTHWOODS CTR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2462
Mailing Address - Country:US
Mailing Address - Phone:618-281-9294
Mailing Address - Fax:618-281-9801
Practice Address - Street 1:242 SOUTHWOODS CTR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2462
Practice Address - Country:US
Practice Address - Phone:618-281-9294
Practice Address - Fax:618-281-9801
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist