Provider Demographics
NPI:1467588236
Name:GULTZ, DOUGLAS B (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:B
Last Name:GULTZ
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:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-0579
Mailing Address - Country:US
Mailing Address - Phone:973-690-5306
Mailing Address - Fax:
Practice Address - Street 1:396 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-2704
Practice Address - Country:US
Practice Address - Phone:973-690-5306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01300900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist