Provider Demographics
NPI:1235146101
Name:MAYER, JERRY ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALAN
Last Name:MAYER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 SOUTH 7TH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638
Mailing Address - Country:US
Mailing Address - Phone:740-532-4613
Mailing Address - Fax:740-532-8099
Practice Address - Street 1:2301 SOUTH 7TH STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638
Practice Address - Country:US
Practice Address - Phone:740-532-4613
Practice Address - Fax:740-532-8099
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5949204E00000X, 1223S0112X
OH190611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64059496OtherMEDICAL PROVIDER NUMBER
OH0751575Medicaid
KY60059490OtherDENTAL PROVIDER NUMBER
KY60059490OtherDENTAL PROVIDER NUMBER
OH0751575Medicaid