Provider Demographics
NPI:1770923575
Name:FREDERICK, EVAN ANDREW (DDS)
Entity type:Individual
Prefix:MR
First Name:EVAN
Middle Name:ANDREW
Last Name:FREDERICK
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 1:323 W CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2805
Mailing Address - Country:US
Mailing Address - Phone:517-278-6077
Mailing Address - Fax:517-278-7045
Practice Address - Street 1:323 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2805
Practice Address - Country:US
Practice Address - Phone:517-278-6077
Practice Address - Fax:517-278-7045
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010209081223G0001X
MI2901010051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice