Provider Demographics
NPI:1942354725
Name:DARYL W FREDERICK DDS PC
Entity type:Organization
Organization Name:DARYL W FREDERICK DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-787-5367
Mailing Address - Street 1:2641 SHIRLEY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8633
Mailing Address - Country:US
Mailing Address - Phone:517-787-5367
Mailing Address - Fax:517-787-4219
Practice Address - Street 1:2641 SHIRLEY DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8633
Practice Address - Country:US
Practice Address - Phone:517-787-5367
Practice Address - Fax:517-787-4219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty