Provider Demographics
NPI:1497043178
Name:FRAZIER, JACOB ELDON (DMD, MS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ELDON
Last Name:FRAZIER
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WAKANDA DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1393
Mailing Address - Country:US
Mailing Address - Phone:618-808-0511
Mailing Address - Fax:618-808-0533
Practice Address - Street 1:110 WAKANDA DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1393
Practice Address - Country:US
Practice Address - Phone:618-808-0511
Practice Address - Fax:618-808-0533
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190287571223G0001X
IL021.0026611223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice