Provider Demographics
NPI:1356572226
Name:JOHN, FREDERICK JEREMY (DMD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:JEREMY
Last Name:JOHN
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 1:4530 S CARSON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-6914
Mailing Address - Country:US
Mailing Address - Phone:775-461-3800
Mailing Address - Fax:
Practice Address - Street 1:4530 S CARSON ST STE 5
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-6914
Practice Address - Country:US
Practice Address - Phone:775-461-3800
Practice Address - Fax:775-461-3801
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS6-1401223P0221X
UT8673083-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00781771Medicaid