Provider Demographics
NPI:1023236221
Name:RAUSCH, JERRY R (DMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:R
Last Name:RAUSCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:GERALD
Other - Middle Name:R
Other - Last Name:RAUSCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:256 LESTER RD SW
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4707
Mailing Address - Country:US
Mailing Address - Phone:770-931-9017
Mailing Address - Fax:
Practice Address - Street 1:1172 ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-2903
Practice Address - Country:US
Practice Address - Phone:770-931-3388
Practice Address - Fax:770-931-3368
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice