Provider Demographics
NPI:1083798649
Name:DOUGLAS, LINDSEY R III (DMD)
Entity Type:Individual
Prefix:DR
First Name:LINDSEY
Middle Name:R
Last Name:DOUGLAS
Suffix:III
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 1:4207 TIETON DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3347
Mailing Address - Country:US
Mailing Address - Phone:509-965-8911
Mailing Address - Fax:509-965-6143
Practice Address - Street 1:4207 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3347
Practice Address - Country:US
Practice Address - Phone:509-965-8911
Practice Address - Fax:509-965-6143
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA90591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5036942Medicaid
AB23313Medicare UPIN