Provider Demographics
NPI:1790821585
Name:FRERICHS, JEFFREY DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:FRERICHS
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 1:2301 VILLAGE GREEN PL STE A
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7630
Mailing Address - Country:US
Mailing Address - Phone:217-352-3455
Mailing Address - Fax:217-352-3481
Practice Address - Street 1:2301 VILLAGE GREEN PL STE A
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7630
Practice Address - Country:US
Practice Address - Phone:217-352-3455
Practice Address - Fax:217-352-3481
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0221671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice