Provider Demographics
NPI:1275535494
Name:FANKHAUSER, GERALD R (DDS)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:R
Last Name:FANKHAUSER
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 1:1200 E WOODHURST DR
Mailing Address - Street 2:STE H100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4260
Mailing Address - Country:US
Mailing Address - Phone:417-883-2214
Mailing Address - Fax:417-883-8697
Practice Address - Street 1:1200 E WOODHURST DR
Practice Address - Street 2:STE H100
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4260
Practice Address - Country:US
Practice Address - Phone:417-883-2214
Practice Address - Fax:417-883-8697
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MO1122501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice