Provider Demographics
NPI:1437454733
Name:STEVE DOUGLAS, DDS, PC
Entity Type:Organization
Organization Name:STEVE DOUGLAS, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-786-1277
Mailing Address - Street 1:6745 GRAY RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-3262
Mailing Address - Country:US
Mailing Address - Phone:317-786-1277
Mailing Address - Fax:317-786-1497
Practice Address - Street 1:6745 GRAY RD
Practice Address - Street 2:SUITE F
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-3262
Practice Address - Country:US
Practice Address - Phone:317-786-1277
Practice Address - Fax:317-786-1497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120093461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100102910AMedicaid