Provider Demographics
NPI:1164827184
Name:GERRAH, SHARONA
Entity Type:Individual
Prefix:
First Name:SHARONA
Middle Name:
Last Name:GERRAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 NW FOXTAIL PL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3882
Mailing Address - Country:US
Mailing Address - Phone:516-946-7711
Mailing Address - Fax:
Practice Address - Street 1:3208 NW FOXTAIL PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3882
Practice Address - Country:US
Practice Address - Phone:516-946-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-03
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11197122300000X
390200000X
TX315741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program