Healthcare Provider Details

I. General information

NPI: 1912355629
Provider Name (Legal Business Name): JONATHON KARL FREDERIKSEN RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 HWY 50
PECOS NM
87552
US

IV. Provider business mailing address

2 AVENIDA DE COMPADRES
SANTA FE NM
87508-8713
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-6666
  • Fax:
Mailing address:
  • Phone: 505-757-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2815
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: