Provider Demographics
NPI:1174658546
Name:FRAZIER, CLIFTON JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:
Last Name:FRAZIER
Suffix:JR
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 1:10300 BAILEY COVE RD SE STE 4
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803-2635
Mailing Address - Country:US
Mailing Address - Phone:256-650-0724
Mailing Address - Fax:256-650-0872
Practice Address - Street 1:1616 PULASKI PIKE NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-2534
Practice Address - Country:US
Practice Address - Phone:256-536-2771
Practice Address - Fax:256-539-5284
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4479332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009967115Medicaid
AL009967105Medicaid
AL009967105Medicaid