Provider Demographics
NPI:1467457499
Name:MACLEOD, DOUGLAS KENNETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KENNETH
Last Name:MACLEOD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 SIX FORKS RD
Mailing Address - Street 2:STE 104
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6427
Mailing Address - Country:US
Mailing Address - Phone:919-848-8444
Mailing Address - Fax:919-848-8445
Practice Address - Street 1:6900 SIX FORKS RD
Practice Address - Street 2:STE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6427
Practice Address - Country:US
Practice Address - Phone:919-848-8444
Practice Address - Fax:919-848-8445
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC95443OtherBLUE CROSS ID
NC8995443Medicaid
NCU40897Medicare ID - Type Unspecified
NC727431Medicare UPIN