Provider Demographics
NPI:1023189297
Name:FRASIER, JEREMIAH J (DDS)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:J
Last Name:FRASIER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:
Practice Address - Street 1:5430 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-6446
Practice Address - Country:US
Practice Address - Phone:317-322-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010442A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200487570Medicaid