Provider Demographics
NPI:1912355629
Name:FREDERIKSEN, JONATHON KARL (RDH)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:KARL
Last Name:FREDERIKSEN
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 AVENIDA DE COMPADRES
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8713
Mailing Address - Country:US
Mailing Address - Phone:505-757-6666
Mailing Address - Fax:
Practice Address - Street 1:199 HWY 50
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:NM
Practice Address - Zip Code:87552
Practice Address - Country:US
Practice Address - Phone:505-757-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH2815124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist