Provider Demographics
NPI:1417002155
Name:DOUGLAS, MICHELLE CHRISTINA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:CHRISTINA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 PENDLETON DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2920
Mailing Address - Country:US
Mailing Address - Phone:304-267-7815
Mailing Address - Fax:304-267-0544
Practice Address - Street 1:315 PENDLETON DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2920
Practice Address - Country:US
Practice Address - Phone:304-267-7815
Practice Address - Fax:304-267-0544
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02320100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist