=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619081064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDERICK ANTHONY FENDERSON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150 CLEARWATER DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-7131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-7051
-----------------------------------------------------
Fax | 928-778-1731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3150 CLEARWATER DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-7131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-7051
-----------------------------------------------------
Fax | 928-778-1731
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 42820
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | D-4566
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------