Provider Demographics
NPI:1164943809
Name:DOUGLASS, TRISHA JANE (RDA)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:JANE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:JANE
Other - Last Name:SMILIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45465 25TH ST E SPC 196
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-2394
Mailing Address - Country:US
Mailing Address - Phone:661-390-2737
Mailing Address - Fax:
Practice Address - Street 1:44558 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3333
Practice Address - Country:US
Practice Address - Phone:661-723-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA733141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice