Provider Demographics
NPI:1417211525
Name:FREDRICK J. PLATT, DDS, PLLC
Entity type:Organization
Organization Name:FREDRICK J. PLATT, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PLATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-592-7111
Mailing Address - Street 1:2020 LINDBERGH ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1714
Mailing Address - Country:US
Mailing Address - Phone:903-592-7111
Mailing Address - Fax:903-535-9210
Practice Address - Street 1:2020 LINDBERGH DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1714
Practice Address - Country:US
Practice Address - Phone:903-592-7111
Practice Address - Fax:903-535-9210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX256701223G0001X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3153009-02Medicaid
TX3153009-01Medicaid