Provider Demographics
NPI:1447591987
Name:DOUGLAS AND KLOSS DENTAL
Entity Type:Organization
Organization Name:DOUGLAS AND KLOSS DENTAL
Other - Org Name:HERITAGE OAK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-626-4050
Mailing Address - Street 1:3700 ATHERTON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3717
Mailing Address - Country:US
Mailing Address - Phone:916-626-4050
Mailing Address - Fax:
Practice Address - Street 1:3700 ATHERTON RD
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3717
Practice Address - Country:US
Practice Address - Phone:916-626-4050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-08
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty