Healthcare Provider Details

I. General information

NPI: 1528143898
Provider Name (Legal Business Name): JOHN FRAZIER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5826 81ST ST
MIDDLE VILLAGE NY
11379-5329
US

IV. Provider business mailing address

5826 81ST ST
MIDDLE VILLAGE NY
11379-5329
US

V. Phone/Fax

Practice location:
  • Phone: 864-580-0263
  • Fax: 866-485-1160
Mailing address:
  • Phone: 864-580-0263
  • Fax: 866-485-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4210
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: