Provider Demographics
NPI:1174052302
Name:FRASER, KELSEY JO (DDS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JO
Last Name:FRASER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4448 PINE COVE RD
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-1335
Mailing Address - Country:US
Mailing Address - Phone:406-853-1676
Mailing Address - Fax:
Practice Address - Street 1:515 N BROADWAY AVE STE 4
Practice Address - Street 2:
Practice Address - City:RED LODGE
Practice Address - State:MT
Practice Address - Zip Code:59068
Practice Address - Country:US
Practice Address - Phone:406-662-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-10
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-13445122300000X
MT134451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist