Provider Demographics
NPI:1245338870
Name:FRALEY, CHRISTIAN SHANNON (DMD)
Entity type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:SHANNON
Last Name:FRALEY
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 1:800 ROSE ST
Mailing Address - Street 2:D104
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0297
Mailing Address - Country:US
Mailing Address - Phone:859-257-9272
Mailing Address - Fax:859-257-9274
Practice Address - Street 1:2400 GREATSTONE PT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-257-9272
Practice Address - Fax:859-257-9274
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60071339Medicaid
KY0007616Medicaid