Provider Demographics
NPI:1225871411
Name:FREDERICK, MELISSA KAYLA (RDH)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:KAYLA
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24404 HIGHFLY CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4706
Mailing Address - Country:US
Mailing Address - Phone:301-653-6443
Mailing Address - Fax:
Practice Address - Street 1:602 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:785-240-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26826124Q00000X
KS13623124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist