Provider Demographics
NPI:1871088062
Name:FRASER, BLAZE (DMD)
Entity type:Individual
Prefix:DR
First Name:BLAZE
Middle Name:
Last Name:FRASER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BAY ST APT 913
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-5918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:289 MARKET ST STE 2
Practice Address - Street 2:
Practice Address - City:SADDLE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07663-6026
Practice Address - Country:US
Practice Address - Phone:201-368-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02736700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist