Provider Demographics
NPI:1982087672
Name:FREDERICK, LINDSAY
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3820
Mailing Address - Country:US
Mailing Address - Phone:330-507-2017
Mailing Address - Fax:
Practice Address - Street 1:13616 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4709
Practice Address - Country:US
Practice Address - Phone:216-221-1438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0270241223G0001X
AZD0092671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid