Healthcare Provider Details

I. General information

NPI: 1699702159
Provider Name (Legal Business Name): MARC D FRIDUSS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4547 SAINT STEPHENS RD
EIGHT MILE AL
36613-3563
US

IV. Provider business mailing address

1725 E SHERMAN BLVD
MUSKEGON MI
49444-1862
US

V. Phone/Fax

Practice location:
  • Phone: 251-456-1399
  • Fax: 251-456-0079
Mailing address:
  • Phone: 231-737-0037
  • Fax: 231-760-5497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019018828
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberLNO 5731
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: