Provider Demographics
NPI:1932570199
Name:ANGELA S FREDERICK, DMD
Entity Type:Organization
Organization Name:ANGELA S FREDERICK, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-784-6436
Mailing Address - Street 1:309 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1659
Mailing Address - Country:US
Mailing Address - Phone:606-784-6436
Mailing Address - Fax:606-784-1665
Practice Address - Street 1:309 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1659
Practice Address - Country:US
Practice Address - Phone:606-784-6436
Practice Address - Fax:606-784-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002953Medicaid