Provider Demographics
NPI:1053493783
Name:WIRTH, DOUGLAS LEE (DMD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:WIRTH
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 1:275 SE CABOT DR
Mailing Address - Street 2:SUITE B-201
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-3715
Mailing Address - Country:US
Mailing Address - Phone:360-675-6404
Mailing Address - Fax:360-240-1301
Practice Address - Street 1:275 SE CABOT DR
Practice Address - Street 2:SUITE B-201
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3715
Practice Address - Country:US
Practice Address - Phone:360-675-6404
Practice Address - Fax:360-240-1301
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000057731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice