Provider Demographics
NPI:1699702159
Name:FRIDUSS, MARC D (DDS)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:D
Last Name:FRIDUSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1862
Mailing Address - Country:US
Mailing Address - Phone:231-737-0037
Mailing Address - Fax:231-760-5497
Practice Address - Street 1:4547 SAINT STEPHENS RD
Practice Address - Street 2:
Practice Address - City:EIGHT MILE
Practice Address - State:AL
Practice Address - Zip Code:36613-3563
Practice Address - Country:US
Practice Address - Phone:251-456-1399
Practice Address - Fax:251-456-0079
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018828122300000X
ALLNO 5731122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL011846OtherMEDICARE GROUP NUMBER
AL1063439065OtherNPI GROUP PAYEE NUMBER
AL630000013Medicaid