Provider Demographics
NPI:1962514265
Name:FREBERG, RANDALL KARL (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:KARL
Last Name:FREBERG
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 1:1486 PALM ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2938
Mailing Address - Country:US
Mailing Address - Phone:805-543-8675
Mailing Address - Fax:805-543-8696
Practice Address - Street 1:1486 PALM ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2938
Practice Address - Country:US
Practice Address - Phone:805-543-8675
Practice Address - Fax:805-543-8696
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3217122300000X
CA0330851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice