Provider Demographics
NPI:1750549325
Name:GERARD, JAKE D (DMD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:D
Last Name:GERARD
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 1:1848 MILLENIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-888-2026
Mailing Address - Fax:208-888-2094
Practice Address - Street 1:1848 MILLENNIUM WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-888-2026
Practice Address - Fax:208-888-2094
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD41331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice