Provider Demographics
NPI:1861621278
Name:CHERRY, ELMER RAYMOND IV (DDS)
Entity type:Individual
Prefix:
First Name:ELMER
Middle Name:RAYMOND
Last Name:CHERRY
Suffix:IV
Gender:M
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:P.O. BOX 919
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455
Mailing Address - Country:US
Mailing Address - Phone:208-787-2323
Mailing Address - Fax:
Practice Address - Street 1:7389 S. HWY. 33 SUITE A
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455
Practice Address - Country:US
Practice Address - Phone:208-787-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4235122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist