Provider Demographics
NPI:1144388398
Name:DOUGLAS, MARK S (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:DOUGLAS
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Gender:M
Credentials:DDS, MSD
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Mailing Address - Street 1:4827 LAGUNA PARK DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5159
Mailing Address - Country:US
Mailing Address - Phone:916-392-1885
Mailing Address - Fax:916-392-1888
Practice Address - Street 1:4827 LAGUNA PARK DR
Practice Address - Street 2:SUITE 5
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5159
Practice Address - Country:US
Practice Address - Phone:916-392-1885
Practice Address - Fax:916-392-1888
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA305361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics