Healthcare Provider Details

I. General information

NPI: 1013075282
Provider Name (Legal Business Name): JERRY EVAN FRASURE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N MAIN ST
CEDARVILLE OH
45314
US

IV. Provider business mailing address

400 N MAIN ST
CEDARVILLE OH
45314
US

V. Phone/Fax

Practice location:
  • Phone: 937-766-5207
  • Fax: 937-766-9303
Mailing address:
  • Phone: 937-766-5207
  • Fax: 937-766-9303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15428
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: