Provider Demographics
NPI:1609985324
Name:FRAZIER-WILZIG, MARY JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JO
Last Name:FRAZIER-WILZIG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:FRAZIER-CAMBOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2428 SANTA MONICA BLVD 402A
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-453-4488
Mailing Address - Fax:310-453-5748
Practice Address - Street 1:2428 SANTA MONICA BLVD 402A
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-453-4488
Practice Address - Fax:310-453-5748
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29272122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist