Provider Demographics
NPI:1033241294
Name:MCDOUGAL, GERALD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:W
Last Name:MCDOUGAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 SHOAL CREEK BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-8051
Mailing Address - Country:US
Mailing Address - Phone:512-454-5219
Mailing Address - Fax:512-323-9516
Practice Address - Street 1:8015 SHOAL CREEK BLVD STE 108
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-8051
Practice Address - Country:US
Practice Address - Phone:512-454-5219
Practice Address - Fax:512-323-9516
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD07089OtherBLUE CROSS BLUE SHIELD