Provider Demographics
NPI:1356414452
Name:HERMANSON, FREDERICK J (DDS, PA)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
Last Name:HERMANSON
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 147TH ST W STE 302
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7538
Mailing Address - Country:US
Mailing Address - Phone:952-432-9155
Mailing Address - Fax:952-431-3155
Practice Address - Street 1:7300 147TH ST W STE 302
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7538
Practice Address - Country:US
Practice Address - Phone:952-432-9155
Practice Address - Fax:952-431-3155
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN96051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice