Healthcare Provider Details

I. General information

NPI: 1982083135
Provider Name (Legal Business Name): ZACHARY T FRAZIER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 FOREST AVE
DOWNERS GROVE IL
60515-3509
US

IV. Provider business mailing address

4909 FOREST AVE
DOWNERS GROVE IL
60515-3509
US

V. Phone/Fax

Practice location:
  • Phone: 630-541-3696
  • Fax: 630-541-9179
Mailing address:
  • Phone: 630-541-3696
  • Fax: 630-541-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019028645
License Number StateIL

VIII. Authorized Official

Name: ZACHARY T FRAZIER
Title or Position: PRESIDENT
Credential: DDS
Phone: 630-541-3696