Provider Demographics
NPI:1588754576
Name:FREDERICK, ANGELA S (DMD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:SMITH
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:309 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1659
Mailing Address - Country:US
Mailing Address - Phone:606-784-6436
Mailing Address - Fax:606-784-1665
Practice Address - Street 1:309 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1659
Practice Address - Country:US
Practice Address - Phone:606-784-6436
Practice Address - Fax:606-784-1665
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6002953Medicaid