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General NPI Number Information
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NPI Number | 1053729921
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Entity Type | Individual
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Provider Name | SANDRA FREDERICK D.D.S
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Gender | Female
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Dates
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Enumeration Date | 07/23/2014
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Last Update Date | 07/23/2014
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Provider Practice Location Address
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Address Line | 31245 HARPER AVE
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48082-1401
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Country | US
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Telephone | 586-783-5505
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Fax |
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Provider Business Mailing Address
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Address Line | 1532 W 13 MILE RD
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City | ROYAL OAK
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State | MI
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Zip | 48073-4504
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Country | US
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Telephone | 586-873-5505
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901021335
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License Number State | MI
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