Healthcare Provider Details

I. General information

NPI: 1003815002
Provider Name (Legal Business Name): JOHN THOMAS FREY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 JUPITER AVE NE SUITE B
BELMONT MI
49306-8708
US

IV. Provider business mailing address

6220 JUPITER AVE NE STE B
BELMONT MI
49306-8709
US

V. Phone/Fax

Practice location:
  • Phone: 616-222-0202
  • Fax: 616-222-0203
Mailing address:
  • Phone: 616-222-0202
  • Fax: 616-222-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901017047
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: