Provider Demographics
NPI:1134173578
Name:FRAZIER, KEVIN BRADLEY (DMD, EDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRADLEY
Last Name:FRAZIER
Suffix:
Gender:M
Credentials:DMD, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE GC-1012
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-2371
Mailing Address - Fax:706-721-6778
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1001
Practice Address - Country:US
Practice Address - Phone:706-721-2371
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9605122300000X
GADNF000246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000689664AMedicaid
GA000689664AMedicaid