Healthcare Provider Details

I. General information

NPI: 1588765077
Provider Name (Legal Business Name): MICHAEL L. FREID
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N NOTRE DAME AVE
SOUTH BEND IN
46617-2839
US

IV. Provider business mailing address

225 N NOTRE DAME AVE
SOUTH BEND IN
46617-2839
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-4868
  • Fax: 574-232-4869
Mailing address:
  • Phone: 574-232-4868
  • Fax: 574-232-4869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12006859A
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL L FREID
Title or Position: PRESIDENT
Credential: DDS
Phone: 574-232-4868