Provider Demographics
NPI:1083700355
Name:PREUSS, JERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:PREUSS
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 1:2 WALTER SCHOLER DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-6382
Mailing Address - Country:US
Mailing Address - Phone:765-477-6100
Mailing Address - Fax:765-477-5911
Practice Address - Street 1:2 WALTER SCHOLER DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-6382
Practice Address - Country:US
Practice Address - Phone:765-477-6100
Practice Address - Fax:765-477-5911
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININD 1200 80251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100231690AMedicaid
12008025OtherINDIANA LICENSE
620525OtherUNITED CONCORDIA
IN805690OtherBLUE CROSS BLUE SHIELD PR