=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881766491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN MICHAEL FREDAL JR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45420 VAN DYKE AVE
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48317-5676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-997-9484
-----------------------------------------------------
Fax | 586-997-9645
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45420 VAN DYKE AVE
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48317-5676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-997-9484
-----------------------------------------------------
Fax | 586-997-9645
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901014489
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------