=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588765077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL L. FREID
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 06/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 N NOTRE DAME AVE
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46617-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-232-4868
-----------------------------------------------------
Fax | 574-232-4869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 N NOTRE DAME AVE
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46617-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-232-4868
-----------------------------------------------------
Fax | 574-232-4869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL L FREID
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 574-232-4868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 12006859A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------