Provider Demographics
NPI:1376625764
Name:SOSEMAN, DOUGLASS J (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLASS
Middle Name:J
Last Name:SOSEMAN
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 1:1415 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:IA
Mailing Address - Zip Code:51442-2052
Mailing Address - Country:US
Mailing Address - Phone:712-263-5615
Mailing Address - Fax:712-263-8124
Practice Address - Street 1:1415 BROADWAY
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:IA
Practice Address - Zip Code:51442-2052
Practice Address - Country:US
Practice Address - Phone:712-263-5615
Practice Address - Fax:712-263-8124
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA066571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1184978Medicaid