Healthcare Provider Details

I. General information

NPI: 1215918198
Provider Name (Legal Business Name): ROSS ANDREW FRASER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7627 LAKE ST SUITE 200
RIVER FOREST IL
60305-1878
US

IV. Provider business mailing address

7627 LAKE ST SUITE 200
RIVER FOREST IL
60305-1878
US

V. Phone/Fax

Practice location:
  • Phone: 708-366-6001
  • Fax: 708-366-6001
Mailing address:
  • Phone: 708-366-6001
  • Fax: 708-366-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: