Jacob Eldon Frazier, DMD, MS

Primary specialty

EndodonticsTaxonomy code 1223E0200X

License

021.002661 Issued in IL

Practice address

110 Wakanda Dr
Lebanon, IL 62254-1393

Phone

(618) 808-0511

Fax

(618) 808-0533

NPI assigned

Jul 15, 2011

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Science

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1310688000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1689724800000",
    "number": "1497043178",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "110 WAKANDA DR",
            "city": "LEBANON",
            "state": "IL",
            "postal_code": "622541393",
            "telephone_number": "618-808-0511",
            "fax_number": "618-808-0533"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "110 WAKANDA DR",
            "city": "LEBANON",
            "state": "IL",
            "postal_code": "622541393",
            "telephone_number": "618-808-0511",
            "fax_number": "618-808-0533"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FRAZIER",
        "first_name": "JACOB",
        "middle_name": "ELDON",
        "credential": "DMD, MS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2011-07-15",
        "last_updated": "2023-07-19",
        "certification_date": "2023-07-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019028757",
            "primary": false
        },
        {
            "code": "1223E0200X",
            "taxonomy_group": "",
            "desc": "Dentist, Endodontics",
            "state": "IL",
            "license": "021.002661",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Covenant Care Midwest, Inc.
• Joshua Parker Craig, ATC
• Sydney Diekhoff, ATC
• Evercare of Lebanon LLC
• Dale A Fischer, DC
• Tonya Gass
• Katy Renee Gayford, ATC, PHD
• Kelsey Gerdes
• Meagan Elise Graul, DMD
• Justin Groennert, O.D.

• Endodontics in Lebanon, IL
• Providers in Lebanon, IL by specialty
• Endodontics in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.