Provider Demographics
NPI:1679874739
Name:FEDERICK, DAVID RICHARD (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHARD
Last Name:FEDERICK
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 1:1000 W CARSON ST
Mailing Address - Street 2:BOX 19
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-668-4675
Mailing Address - Fax:310-638-2529
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 19
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-668-4675
Practice Address - Fax:310-638-2529
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277541223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics