Provider Demographics
NPI:1912910589
Name:BUNCH, FREDERICK LYLE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:LYLE
Last Name:BUNCH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:756 PORTER AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4232
Mailing Address - Country:US
Mailing Address - Phone:209-951-6387
Mailing Address - Fax:209-951-2824
Practice Address - Street 1:756 PORTER AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4232
Practice Address - Country:US
Practice Address - Phone:209-951-6387
Practice Address - Fax:209-951-2824
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA219741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2197401Medicaid
CAB2197401Medicaid