Healthcare Provider Details

I. General information

NPI: 1841979010
Provider Name (Legal Business Name): OLIVIA L FRASER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E. HOSPITAL ROAD
FORT GORDON GA
30905
US

IV. Provider business mailing address

524 BRIGADIER LNDG
GROVETOWN GA
30813-3360
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-6736
  • Fax:
Mailing address:
  • Phone: 254-289-6151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN123165
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: