Provider Demographics
NPI:1710177233
Name:FRAZIER, JILL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:GAMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:715 KENSINGTON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5769
Mailing Address - Country:US
Mailing Address - Phone:406-549-6222
Mailing Address - Fax:
Practice Address - Street 1:715 KENSINGTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5769
Practice Address - Country:US
Practice Address - Phone:406-549-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT19441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0005511179Medicaid