MEDICARE: DR. DERRICK ONEAL FRYE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DE015374	MO

General Provider Information

NPI Number	:	1558532127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DERRICK ONEAL FRYE DDS

Provider Business Mailing Address
First Line	:	7843 OLIVE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-2039
Country	:	US
Telephone Number	:	314-863-3772
Fax Number	:	314-863-3857

Provider Business Practice Location Address
First Line	:	7843 OLIVE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-2039
Country	:	US
Telephone Number	:	314-863-3772
Fax Number	:	314-863-3857

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2008
Last Update Date	:	03/21/2008

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