Provider Demographics
NPI:1871573857
Name:DISQUE, FREDRICK C (DMD)
Entity type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:C
Last Name:DISQUE
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 1:600 E MARSHALL ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4441
Mailing Address - Country:US
Mailing Address - Phone:610-431-2161
Mailing Address - Fax:610-431-2173
Practice Address - Street 1:600 E MARSHALL ST
Practice Address - Street 2:SUITE 106
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4441
Practice Address - Country:US
Practice Address - Phone:610-431-2161
Practice Address - Fax:610-431-2173
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS016669L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery