Provider Demographics
NPI:1588765077
Name:MICHAEL L. FREID
Entity type:Organization
Organization Name:MICHAEL L. FREID
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:FREID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-232-4868
Mailing Address - Street 1:225 N NOTRE DAME AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2839
Mailing Address - Country:US
Mailing Address - Phone:574-232-4868
Mailing Address - Fax:574-232-4869
Practice Address - Street 1:225 N NOTRE DAME AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2839
Practice Address - Country:US
Practice Address - Phone:574-232-4868
Practice Address - Fax:574-232-4869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006859A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100220550Medicaid
IN727870Medicare ID - Type UnspecifiedMEDICARE