MEDICARE: SCOTT J FRIDRICH DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	104873	CO

General Provider Information

NPI Number	:	1972840460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT J FRIDRICH DDS PC

Provider Business Mailing Address
First Line	:	1120 ALPINE AVE STE C
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80304-3414
Country	:	US
Telephone Number	:	303-443-4416
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 ALPINE AVE STE C
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80304-3414
Country	:	US
Telephone Number	:	303-443-4416
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR OF DENTAL SURGERY
Name	:	DR. SCOTT JOSEPH FRIDRICH
Credential	:	DDS
Telephone Number	:	303-443-4416

Provider Enumeration Date	:	01/03/2013
Last Update Date	:	01/03/2013

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