Provider Demographics
NPI:1174636799
Name:KISTLER, DOUGLAS G (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:G
Last Name:KISTLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 ROTH CHURCH RD
Mailing Address - Street 2:SPRING GROVE PROFESSIONAL CENTER
Mailing Address - City:SPRING GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17362-1406
Mailing Address - Country:US
Mailing Address - Phone:717-225-5741
Mailing Address - Fax:
Practice Address - Street 1:26 ROTH CHURCH RD
Practice Address - Street 2:SPRING GROVE PROFESSIONAL CENTER
Practice Address - City:SPRING GROVE
Practice Address - State:PA
Practice Address - Zip Code:17362-1406
Practice Address - Country:US
Practice Address - Phone:717-225-5741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO29459L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice