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General NPI Number Information
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NPI Number | 1790904589
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Entity Type | Individual
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Provider Name | NICHOLAS ANTHONY FREDERICKA D.M.D
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Gender | Male
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 07/25/2008
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Provider Practice Location Address
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Address Line | 120 BOVARD ST
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City | YERINGTON
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State | NV
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Zip | 89447-2437
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Country | US
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Telephone | 775-463-1800
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Fax | 775-463-4810
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Provider Business Mailing Address
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Address Line | 120 BOVARD ST
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City | YERINGTON
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State | NV
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Zip | 89447-2437
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Country | US
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Telephone | 775-463-1800
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Fax | 775-463-4810
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30016140
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License Number State | OH
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