Provider Demographics
NPI:1275676488
Name:LALLY, FREDERICK C (DDS,)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:C
Last Name:LALLY
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 1:164 W TIOGA ST
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-1466
Mailing Address - Country:US
Mailing Address - Phone:570-836-6362
Mailing Address - Fax:
Practice Address - Street 1:164 W TIOGA ST
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-1466
Practice Address - Country:US
Practice Address - Phone:570-836-6362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020916-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist