Provider Demographics
NPI:1316029374
Name:DR FREDERIC CLYDE RATHER DMD PC
Entity type:Organization
Organization Name:DR FREDERIC CLYDE RATHER DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:RATHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-836-5656
Mailing Address - Street 1:9042 COLUMBIA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2905
Mailing Address - Country:US
Mailing Address - Phone:219-836-5656
Mailing Address - Fax:219-836-0455
Practice Address - Street 1:9042 COLUMBIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2905
Practice Address - Country:US
Practice Address - Phone:219-836-5656
Practice Address - Fax:219-836-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008608A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1447260732OtherINDIVISUAL NPI