Provider Demographics
NPI:1437484128
Name:DOUGLAS, BETHANY ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:ANN
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 1:1060 OAKVALE RD
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-3823
Mailing Address - Country:US
Mailing Address - Phone:904-671-3799
Mailing Address - Fax:
Practice Address - Street 1:9109 BAYMEADOWS RD STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1842
Practice Address - Country:US
Practice Address - Phone:904-265-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0140011223E0200X
FLDN190931223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics