Provider Demographics
NPI:1841979010
Name:FRASER, OLIVIA L (DMD)
Entity type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:L
Last Name:FRASER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LAQUESHA
Other - Middle Name:OLIVIA
Other - Last Name:FRASER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:524 BRIGADIER LNDG
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-3360
Mailing Address - Country:US
Mailing Address - Phone:254-289-6151
Mailing Address - Fax:
Practice Address - Street 1:25501 BRAINARD AVE
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist