Provider Demographics
NPI:1881099802
Name:FREDERICK DANIELS,DDS,FAMILY DENTISTRY,LLC
Entity type:Organization
Organization Name:FREDERICK DANIELS,DDS,FAMILY DENTISTRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-875-6269
Mailing Address - Street 1:12 GOOSE LN
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-3400
Mailing Address - Country:US
Mailing Address - Phone:860-875-6269
Mailing Address - Fax:860-870-5606
Practice Address - Street 1:12 GOOSE LN
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3400
Practice Address - Country:US
Practice Address - Phone:860-875-6269
Practice Address - Fax:860-870-5606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0050301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty