Provider Demographics
NPI:1164527297
Name:ROSS, DOUGLAS L (DMD10)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:ROSS
Suffix:
Gender:M
Credentials:DMD10
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247-9126
Mailing Address - Country:US
Mailing Address - Phone:360-966-7777
Mailing Address - Fax:360-966-4510
Practice Address - Street 1:201 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9126
Practice Address - Country:US
Practice Address - Phone:360-966-7777
Practice Address - Fax:360-966-4510
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA90091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice