Provider Demographics
NPI:1003938663
Name:DOUGLAS, ROBERT DUANE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DUANE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S BELLWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2086
Mailing Address - Country:US
Mailing Address - Phone:618-258-1300
Mailing Address - Fax:
Practice Address - Street 1:160 S BELLWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2086
Practice Address - Country:US
Practice Address - Phone:618-258-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210020251223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics