Healthcare Provider Details

I. General information

NPI: 1053401810
Provider Name (Legal Business Name): FREDERICK J. GEHRKE JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 BISHOP RD
WICKLIFFE OH
44092-2670
US

IV. Provider business mailing address

2860 BISHOP RD
WICKLIFFE OH
44092-2670
US

V. Phone/Fax

Practice location:
  • Phone: 440-585-0011
  • Fax:
Mailing address:
  • Phone: 440-585-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number18967
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: