Basic Information
| Provider Information | |||||||||
| NPI: | 1699702159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIDUSS | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 E SHERMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317370037 | ||||||||
| FaxNumber: | 2317605497 | ||||||||
| Practice Location | |||||||||
| Address1: | 4547 SAINT STEPHENS RD | ||||||||
| Address2: | |||||||||
| City: | EIGHT MILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366133563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514561399 | ||||||||
| FaxNumber: | 2514560079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019018828 | IL | N | Dental Providers | Dentist | 122300000X | LNO 5731 | AL | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 011846 | 01 | AL | MEDICARE GROUP NUMBER | OTHER | 1063439065 | 01 | AL | NPI GROUP PAYEE NUMBER | OTHER | 630000013 | 05 | AL | MEDICAID |