Provider Demographics
NPI:1366524357
Name:JERUD, LORRAINE RACHEL (DR)
Entity type:Individual
Prefix:DR
First Name:LORRAINE
Middle Name:RACHEL
Last Name:JERUD
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:VENTNOR CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08406-2943
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 S NASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:VENTNOR CITY
Practice Address - State:NJ
Practice Address - Zip Code:08406-2943
Practice Address - Country:US
Practice Address - Phone:856-589-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ133681223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics