Provider Demographics
NPI:1831365006
Name:FRED W CARPENTER DDS
Entity type:Organization
Organization Name:FRED W CARPENTER DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-771-7719
Mailing Address - Street 1:1514 WHITE BEAR AVE
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1695
Mailing Address - Country:US
Mailing Address - Phone:651-771-7719
Mailing Address - Fax:651-774-3712
Practice Address - Street 1:1514 WHITE BEAR AVE
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1695
Practice Address - Country:US
Practice Address - Phone:651-771-7719
Practice Address - Fax:651-774-3712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1588636773Medicare PIN