Provider Demographics
NPI:1336366889
Name:FREYTAG, JODY (DDS)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:FREYTAG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 SYCAMORE LN
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43465-1018
Practice Address - Country:US
Practice Address - Phone:419-666-1776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH215621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2636651Medicaid