Provider Demographics
NPI:1043360167
Name:FRACHELLA, JOHN CHARLES (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:FRACHELLA
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:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:OR
Mailing Address - Zip Code:97750-0254
Mailing Address - Country:US
Mailing Address - Phone:541-462-3055
Mailing Address - Fax:
Practice Address - Street 1:1424 SW 15TH
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:47756
Practice Address - Country:US
Practice Address - Phone:406-338-6182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD88411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry