Provider Demographics
NPI:1275061822
Name:DOUGLAS, WERONIKA PAULA (DDS)
Entity Type:Individual
Prefix:
First Name:WERONIKA
Middle Name:PAULA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11052 S SHILLING AVE APT 3413
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4239
Mailing Address - Country:US
Mailing Address - Phone:915-633-5409
Mailing Address - Fax:
Practice Address - Street 1:3650 JOE BATTLE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-2628
Practice Address - Country:US
Practice Address - Phone:915-858-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX328471223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice