Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | AL5271 | AL |
Y | 204E00000X | Oral & Maxillofacial Surgeon | AL28212 | AL |
NPI | 1346397239 |
---|---|
Provider Name | Jonathan Frederick |
First Address | Sheffield, AL 35660-1729 |
Second Address | Sheffield, AL 35660-1729 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 15/11/2011 |