Healthcare Provider Details

I. General information

NPI: 1194017699
Provider Name (Legal Business Name): ZACHARY T. FRAZIER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 LARRY POWER RD
BOURBONNAIS IL
60914-4430
US

IV. Provider business mailing address

376 LARRY POWER RD
BOURBONNAIS IL
60914-4430
US

V. Phone/Fax

Practice location:
  • Phone: 815-802-1217
  • Fax:
Mailing address:
  • Phone: 815-802-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.002521
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: