MEDICARE: DR. JEFFREY DAVID FRERICHS D.D.S.

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	1223G0001X	General Practice Dentistry	19-022167	IL

General Provider Information

NPI Number	:	1790821585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY DAVID FRERICHS D.D.S.

Provider Business Mailing Address
First Line	:	2301 VILLAGE GREEN PL STE A
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-7630
Country	:	US
Telephone Number	:	217-352-3455
Fax Number	:	217-352-3481

Provider Business Practice Location Address
First Line	:	2301 VILLAGE GREEN PL STE A
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-7630
Country	:	US
Telephone Number	:	217-352-3455
Fax Number	:	217-352-3481

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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