Provider Demographics
NPI:1053747717
Name:LEVIN, FRED JACK (DMD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:JACK
Last Name:LEVIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 FOXSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-3983
Mailing Address - Country:US
Mailing Address - Phone:717-569-6487
Mailing Address - Fax:717-581-5487
Practice Address - Street 1:131 FOXSHIRE DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-3983
Practice Address - Country:US
Practice Address - Phone:717-569-6487
Practice Address - Fax:717-581-5487
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS17799L1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics