MEDICARE: DR. JACK C. FREDRICKSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2079	AZ

General Provider Information

NPI Number	:	1427017979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK C. FREDRICKSON D.D.S.

Provider Business Mailing Address
First Line	:	2061 BRYCE CIR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-8352
Country	:	US
Telephone Number	:	928-855-6505
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 MESQUITE AVE
Second Line	:	STE. 8
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5674
Country	:	US
Telephone Number	:	928-855-4347
Fax Number	:	928-855-6894

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	07/08/2007

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