Provider Demographics
NPI:1558640888
Name:FRY, NATHAN DAVID (DMD)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:DAVID
Last Name:FRY
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 1:2503 CHARLEVOIX AVE.
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-347-5317
Mailing Address - Fax:231-347-7933
Practice Address - Street 1:2503 CHARLEVOIX AVE.
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-347-5317
Practice Address - Fax:231-347-7933
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020440122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist