Provider Demographics
NPI:1245384494
Name:LAURIE, DOUGLAS BRUCE (DMD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:BRUCE
Last Name:LAURIE
Suffix:
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 1:809 DAVIS STREET
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-1709
Mailing Address - Country:US
Mailing Address - Phone:619-993-8537
Mailing Address - Fax:760-789-8537
Practice Address - Street 1:327 3RD ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2401
Practice Address - Country:US
Practice Address - Phone:760-789-8537
Practice Address - Fax:760-788-8680
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA270191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice