Provider Demographics
NPI:1306034871
Name:FRASER, GORDON CLELAND JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:CLELAND
Last Name:FRASER
Suffix:JR
Gender:M
Credentials:DMD
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 2213
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269
Mailing Address - Country:US
Mailing Address - Phone:770-483-4469
Mailing Address - Fax:770-922-0401
Practice Address - Street 1:1916 IRIS DRIVE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:770-483-4469
Practice Address - Fax:770-922-0401
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126841223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics