Provider Demographics
NPI:1013075282
Name:FRASURE, JERRY EVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:EVAN
Last Name:FRASURE
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 1:400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45314
Mailing Address - Country:US
Mailing Address - Phone:937-766-5207
Mailing Address - Fax:937-766-9303
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:OH
Practice Address - Zip Code:45314
Practice Address - Country:US
Practice Address - Phone:937-766-5207
Practice Address - Fax:937-766-9303
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH154281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice